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DISEASES 



OF THE 



Urinary Organs 



INCLUDING 



Diabetes Mellitus and Insipidus 



CLIFFORD MITCHELL. A. B., M. D. 

Professor of Renal Diseases in the Chicago Homoeopathic Medi- 
cal College, Urologist to the Chicago Laboratory 
for Clinical Diagnosis. 



ILLUSTRATED. 



PHILADELPHIA : 

BOERICKE & TAFEL. 
1903. 





THE LIBRARY OF 
CONGRESS, 

Two Copies Received 

SEP 26 1903 

^Copyright Entry 

CLASS CL XXc. No 

COPY B. 






COPYRIGHT : 
BOERICKE & TAFEX. 

1903. 



DEDICATION. 



To the General Practitioner Who 
in These Days Has Need to Be a 
"Specialist in Everything" This 
Book Is Respectfully Dedicated. 



PREFACE. 



It will be seen from the dedication that this book has been 
written for the purpose of giving special information in re- 
gard to diseases of the urinary tract to the general practi- 
tioner, who may any moment have need of knowledge so 
scattered about through literature as to be practically, inac- 
cessible to him. Effort has been made to give special promi- 
nence to the diagnosis and treatment of diseases of the kid- 
neys, ureters, bladder, prostate and urethra, together with 
diabetes mellitus and insipidus. Inasmuch as modern sur- 
gery is playing an important part in the treatment of many 
urinary diseases, the writer has devoted considerable space to 
a consideration of the surgical treatment of such maladies. 

It is believed that death may be prevented and suffering 
alleviated by an expert surgeon in a number of urinary dis- 
eases heretofore deemed solely within the province of internal 
medicine. While it may not be possible for the general 
practitioner to perform certain difficult surgical operations, he 
should at least become aware that his patient may possibly 
be saved by surgical means. 

In the matter of general treatment much attention has 
been given by the writer to minute particulars of diet, climate 
and hygiene, upon which success in the management of a 
case so much depends. 

In outlining a course of medical treatment effort has been 
made to be as broad as possible and to include almost every- 
thing recommended by earnest and reliable workers in the 
field of internal medicine. The writer has endeavored to 
specify as clearly as possible what remedies he himself has 
used and with what success. 



VI PREFACE. 

Inasmuch as intelligent treatment of diseases of this nature 
requires a special knowledge of pathology, considerable atten- 
tion has been given to this branch of the subject. The 
pathological classification adopted is that advised by Riesman 
in the American Text-Book of Pathology. 

The writer must acknowledge his obligation to Dr. Charles 
Adams, of Chicago, for much valuable information in regard 
to modern surgery in its application to diseases of the urinary 
organs. 

It is hoped that by means of this volume the treatment of 
urinary diseases — so obscure and so difficult to manage — may 
be made a little easier for the general practitioner. 

70 State St., Chicago, Sept. /, ipoj. 



TABLE OF CONTENTS 



Page. 

CHAPTER I. Anatomy, Physiology, and Pathological Classifi- 
cation, 17 

CHAPTER II. Physical Examination of thf Kidneys, .... 40 

CHAPTER III. General Clinical Features of Renal Disease, . 47 

CHAPTER IV. Anomalies of the Kidneys: Misplacements, mov- 
able kidney, floating kidney, horse-shoe kidney, lobulated kidney, 
anomalies of size, solitary kidney , nonsymmetrical kidney, absence of 
the kidneys, 53 

CHAPTER V. The Uremic Phenomena of Renal Disease: Acute 
Uremia. Chronic Uremia: Etiology, pathology, diagnosis, treat- 
ment. The methylene blue test, phloridzin diabetes, cryoscopy, . . 71 

CHAPTER VI. Disturbances of the Circulation of the Kid- 
nrys: Thrombosis, embolism, aneurism, anemia; hyperemia, active 
and passive, 89 

CHAPTER VII. Inflammations of the Kidney: Classification. 
Acute nephritis: Parenchymatous, diffuse: post-scarlatinal, in 
measles, chicken-pox, malaria, whooping-cough, infectious sore 
throat, acute arthritis, diphtheria, pneumonia, typhoid fever, 
yellow fever, cholera, the plague, gastro-enteritis, from exposure, 
alcoholic, interstitial; the acute nephritis of pregnancy 112 

CHAPTER VIII. Chronic Non-Indurative Nephritis: Chronic 
diffuse nephritis without induration (chronic Bright's disease with 
dropsy) formerly called chronic parenchymatous nephritis. Chronic 
hemorrhagic nephritis without edema, 161 

CHAPTER IX. Chronic Indurative Nephritis: Chronic diffuse 
nephritis with induration, including secondary interstitial nephritis 
(atrophy of the kidney), primary interstitial nephritis (contracting 
kidney), and arteriosclerotic nephritis, 204 

CHAPTER X. Degenerations and Infiltrations of the Kidney. 
Trauma. Fistula. Amyloid kidney. Calcareous and other infiltra- 
tions, pigmentations, hyaline degeneration, cloudy swelling, fatty 
change, chronic degeneration, syphilis of the kidney. Leprosy, 
glanders, actinomycosis, and leukemia. Injuries to the kidney. 
Fistula of the kidney, 252 



^^m 



YUl TABLE OF CONTENTS. 

Page. 

CHAPTER XI. Suppurative Nephritis and Paranephritis (Para- 
nephric Abscess), 266 

CHAPTER XII. Cysts and Tumors of the Kidney: Cystic kidney, 
hydatids, dermoid cysts, benign and malignant tumors, hyper- 
nephroma, 280 

CHAPTER XIII. Tuberculosis of the Kidney, 305 

CHAPTER XIV. Diseases of the Pelvis of the Kidney and of 
The Ureters: Malformation, dilatation {Hydronephrosis, Pyo- 
nephrosis), hyperemia, hemorrhage, edema, inflammation {Pyelitis), 
tuberculosis, tumors, cysts, parasites, stone (Calculus) . Ureteritis, . 321 

CHAPTER XV. Various Abnormal States of the Urine: Dithuria 
or uricaciduria, oxaluria, phosphaturia, cystinuria, alkaptonuria, 
chyluria, hematuria, hemoglobinuria, 380 

CHAPTER XVI. Diseases of thE Bladder: Malformations, mal- 
positions, dilatation, hypertrophy, atrophy, paralysis, irritability, 
circulatory disturbances, amyloid degeneration, inflammation 
(Cystitis), tuberculosis, syphilis, tumors, cysts, parasites, stone 
( Vesical Calculus), wounds, rupture, 404 

CHAPTER XVH. Diseases of The Prostate: Malformations, 
atrophy, hypertrophy, congestion, inflammation, tuberculosis, 
tumors, cysts, and calculi, 482 

CHAPTER XVIII. Diseases of The Urethra: Malformations, 
wounds and rupture, hemorrhage, stricture, tuberculosis, syphilis, 
tumors, calculi and foreign bodies, inflammation (Posterior 
Urethritis, Urethritis). Urinary Fever, 511 

CHAPTER XIX. Enuresis, '. ... 523 

CHAPTER XX. Diabetes Mellitus and Insipidus, 530 

CHAPTER XXI. Clinical Memoranda: The mortality in 500 of the 
writer's cases of albuminuria. Diagnostic summary of thirty-three 
urinary diseases (useful for medical students studying for examina- 
tions). Pain as a clinical symptom of urinary diseases: thirty-five hints 
derived from observation of many cases. Uremia in its clinical 
bearing. The uremia of elderly men. Sequences and complications 
of urinary diseases. Examination of the urine as an aid to 
prognosis. Synopsis of modern renal pathology. Clinical notes, . 611 



CHAPTER I. 

ANATOMY AND PHYSIOLOGY OF THE KIDNEYS. 
PATHOLOGICAL CLASSIFICATION. 

The kidneys are two in number, and are glandular organs 
intended for the excretion of urine. From the arrangement 
of the tubules the kidney is classified- among the coinpound 
tubular glands. 

Development. — The kidney is developed from the so-called 
mesonephros, an outgrowth from the lower end of the Wolf- 
fian duct of the embryo. 

Location. — At the upper and back part of the abdominal 
cavity, on either side of the spinal column, behind the perito- 
neum. The upper border corresponds with the space between 
the eleventh and twelfth ribs, the lower border with the 
middle of the third lumbar vertebra. They rest against the 
crura of the diaphragm and the anterior lamella of the poste- 
rior aponeurosis of the transversalis muscle, and to a slight 
extent on the psoas muscle. 

The kidneys are almost completely enclosed by the ribs, 
and project only slightly beyond the twelfth rib. They lie in 
beds of fat and connective tissue. 

The right kidney is usually a little lower than the left, 
owing to the liver above it crowding it down. 

Fig. i shows the location of the kidneys with reference to 
the viscera, vertebrae and ribs. 

Topography. — Anteriorly : — A horizontal line passing 
through the umbilicus lies just below the lower borders of 
both kidneys. A vertical line drawn perpendicularly from 
the middle of Poupart's ligament upward to the costal arch 
passes directly over the kidney a little external to its median 
line. 

2 



18 



ANATOMY AND PHYSIOLOGY OF THE KIDNEYS. 



Posteriorly : — A line parallel with the spinal column and 
one inch from it, extending from the lower edge of the tip of 
the spinous process of the eleventh dorsal vertebra to the 




Fig. i. — Diagram showing relation of the viscera to the parietes (posterior view). S, 
stomach; L, liver; K, kidney; SP, spleen; R, rectum.— (Treves.) 

lower edge of the spinous process of the third lumbar verte- 
bra, would fall just inside the inner border of the kidney. If 
two lines be drawn from the ends of the line above described 



POSITION OF SURFACES. 



19 



horizontally outward for two and three-fourths inches, and 
the outer ends of these two lines joined by a perpendicular 
line, the whole kidney will normally lie within the four lines 
so drawn. 

Position of Surfaces. — The anterior surfaces look obliquely 
outward and forward from either side of the bodies of the ver- 
tebrae. The posterior surfaces, which are rather more flat- 
tened than the anterior, look obliquely backward and inward 
toward the spines of the vertebrae. The upper end of the 




Fig. 2. — Showing the normal surface relations of the kidneys anteriorly, and the 
method of determining these relations — (Butler.) 



kidney is nearer the spinal column, and is slightly more 
posterior in position than the lower end. The inner border 
of the kidney at its upper part is about an inch from the 
middle line of the body, while the outer border at its lower 
part is three and three-fourths inches from the middle line. 
The outer or convex border of the kidney looks obliquely 
upward, while the concave or inner border looks obliquely 
downward and forward. 



20 



ANATOMY AND PHYSIOLOGY OF THE KIDNEYS. 



Relations of the Left Kidney. — Anteriorly the left kidney 
has the stomach in front of its upper third, the splenic artery 
and pancreas in front of its middle third, and the descending 
colon in front of its lower third. Posteriorly its relations are 
the same as those of the right kidney. Exteriorly the left 
kidney lies against the spleen for the upper two-thirds or 
three-quarters of its extent. 




Fig. 3. — Relations of the kidneys. 1-1, the two kidneys; 2-2, fibrous capsules; 3, pelvis 
of the kidnej-; 4, ureter; 5. renal artery; 6, renal vein; 7, suprarenal body; 8-8, liver, 
raised to show relations of its lower surface to right kidney; 9, gall-bladder; 10, terminus 
of portal vein; 11, origin of common bile-duct; 12, spleen, turned outward to show rela- 
tions with left kidney; 13, semicircular pouch on which the lower end of the spleen rests; 
14, abdominal aorta;" 15, vena cava inferior; 16, left spermatic vein and artery; 17, right 
spermatic vein opening into vena cava inferior; iS, subperitoneal fibrous layer or fascia 
propria, dividing to form renal sheaths; 19, lower end of quadratus lumborum muscle. — 
(Sappey.) 

Incisions for reaching the kidney, if carried too high, may 
open into the pleural cavity, the parietal reflection of which 
is represented by a line crossing the neck of the twelfth rib 
and the outer end of the eleventh. 

Relations of the Right Kidney. — Anteriorly the right kid- 
ney is crossed in its upper half by the right lobe of the liver, 



RELATIONS OF THE RIGHT KIDNEY. 



21 



in its lower half by the ascending colon and descending duo- 
denum, where they are uncovered by the peritoneum, the 
duodenum covering the inner quarter of the lower half. The 
suprarenal capsule at its upper end touches the liver. The 
peritoneum covers it anteriorly near the upper end, the tunica 
adiposa intervening. 

Posteriorly the kidneys rest upon the crura of the dia- 
phragm in front of the eleventh and twelfth ribs, the quad- 
ratus lumborum, and psoas muscles, from which they are 

4 




Fig. 4.— Relations of viscera (anterior view). 1, right kidney; 5, left kidney ; 2 and 3, 
suprarenal capsules ; 4, pancreas ; 6 and 9, ascending and descending colon ; 7, duo- 
denum ; 8, its junction with the jejunum.— (Quain.) 

separated by the diaphragmatic fascia from the first, the 
anterior layer of the lumbar fascia from the second, and by 
the ilio-psoas fascia from the third. Behind it pass the 
twelfth dorsal, ilio-hypogastric and ilio-inguinal nerves. Ex- 
teriorly the right kidney lies against the liver for its upper 
three-quarters. On the inner side are the arteries, veins and 
exit of ureters. The superior extremity is in contact with its 
suprarenal capsule, which rests on the upper and inner mar- 
gin. 



22 ANATOMY AND PHYSIOLOGY OF THE KIDNEYS. 

The relations of the kidneys are shown by Figs. 3 and 4. 

Support. — Adipose and connective tissue {tunica adiposa) 
form the support of the kidneys, and, together with the 
blood-vessels, nerves, lymphatics, and ureters, hold them in 
position. The tunica adiposa itself is a thick layer of fat 
contained in the meshes of a loose areolar tissue, completely 
investing everywhere the fibrous capsule of the kidneys, 
but thicker and more abundant posteriorly than anteriorly. 

Dimensions. — The long axis of the kidney is vertical and 
in length about four inches (10 centimeters), the width is 
about two and one-half inches, and the thickness one and one- 
quarter inches, varying in individual cases. The left kidney 
is usually slightly longer and narrower than the right. 

Weight. — Bach kidney weighs from four and a-half to six 
ounces (125 to 168 grammes) in the male and two or three 
drachms less in the female. The left kidney in both sexes 
weighs about 100 grains (6.5 gm.) more than the right. The 
specific gravity of the renal substance is 1.050, and it contains 
about 83 per cent, of water. In the child the kidney is ^V the 
body-weight ; in youths and adults ^io- 

Form. — The form of the kidney is that of a haricot or kid- 
ney-bean, compressed from either side, presenting an anterior 
and a posterior surface, both of which are slightly convex, 
the anteiior more so. The superior and inferior extremities 
of the kidney are somewhat wider than the middle of the or- 
gan, the superior being thick and rounded, while the inferior 
is thinner and more pointed. The external border is convex ; 
the internal concave, with a deep notch in the centre called 
the hilum, through which pass the vessels, nerves, lymphatics* 
and ureter. The hilum is the perceptible notch, but the 
cavity in the substance of the gland is called the sinus 
renalis. 

Color. — The color of the kidney is red brown. 

Derivation of Vessels, Nerves, and Lymphatics. — The 
arteries are derived from the aorta, the veins empty into the 



THE TUNICA ADIPOSA AND THE CAPSUEE. 23 

rena cava, the lymphatics into the receptaculum chyli. The 
kidney is plentifully supplied with nerves from the solar 
plexus, the semilunar ganglion, and the splanchnic nerves. 
They completely surround the tubules and blood-vessels, and 
also communicate with the spermatic plexus. Dr. M. Hol- 
brook has shown that every epithelium is in connection with 
a nerve-fibre, indirectly, through the inter-epithelial filaments 
of living matter. 

As to the lymphatics, very little is known. In the capsule 
of the kidney there is a regular lymphatic ^system, and in the 
hilum several large lymph-vessels are found which are sup- 
plied with valves. 

The Tunica Adiposa. — This has already been described 
under Support. The amount of fat in it varies according to 
the individual. In thin persons so much of the fat may be 
absorbed that the tunica adiposa becomes loose, and its con- 
nections with the kidney and surrounding parts so relaxed 
that the kidneys acquire no little mobility. In fat persons 
the size of the tunica adiposa may lead to erroneous con- 
clusions as to the size of the kidneys themselves. 

The fat-capsule is continuous with the subperitoneal fat- 
tissue — a matter of importance, as we shall learn further on. 

The Capsule. — By this term is understood the fibrous 
capsule of the kidney, which lies everywhere under the fat- 
capsule (tunica adiposa), and from which the blood-vessels 
penetrate the kidney tissue. It is thin, firm, smooth, and 
closely fitting. Its composition is of numerous, firm, elastic 
fibres, which may be stretched or contracted to a considerable 
degree by the state of vascular tension of the kidney. It is con- 
nected with the organ by fine fibrillated connective tissue and 
minute blood-vessels. In the healthy state the capsule can be 
readily separated from the kidney. 

In chronic interstitial nephritis, however, the connecting 
fibres undergo inflammatory thickening and increase in num- 
ber, causing adhesion of the capsule to the kidney. The 



24 



ANATOMY AND PHYSIOLOGY OF THE KIDNEYS. 



capsule follows the notch or hilum in the renal substance, 
passes into the sinus of the kidney, and becomes continuous, 
around the bases of the papillae of the pyramids, with the 
stronger external fibres and elastic tissues of the calyces and 
pelvis. 



Capsule 



Pelvis 




Ureter 

^_.\_ Infundibulum 

Sections of vessels 
.Cortical Portion 



Fig. 5. — Section of the kidne}' showing gross anatom3'. 

The Kidney Itself consists of two portions, the cortical 
and the medullary. The thickness of the cortex, compared 
with the medulla, is as one to three. Fig. 5 shows the gross 
anatomy of a section of the kidney. 

The Cortical Portion of the Kidney. — This lies directly 
under the capsule, and is the more vascular. It is about 
6.25 mm. (about one-quarter of an inch) in thickness, and 



THE MEDULLARY PORTION. 25 

sends prolongations between the pyramids, whose bases it 
surmounts, as far as the sinus. 

These inter-pyramidal portions of the cortex are known 
as the Columns of Bertini, and mark the original divisions of 
the kidneys into lobules. The portion of the cortical sub- 
stance which stretches from one column of Bertini to another, 
and which surrounds the base of the pyramids, is called the 
cortical arch. The columns and arches together form the 
Labyrinth of Ludwig. 

The Medullary Portion. — This is divided into two parts 
— the boundary or intermediace zone or margin, and the 
papillary zone — and consists of from eight to eighteen coni- 
cal masses, called Pyramids of Malpighi, whose bases rest on 
the cortical portion and whose apices converge toward the 
centre, where they form what are known as papillae, which 
project into the calyces, which are the ultimate divisions of 
the pelvis. (The calyces are from seven to thirteen in num- 
ber, and converge to form the three primary divisions of the 
pelvis called infundibula.) 

The pyramids (Fig. 6) are plainly striated, these striations 
always being straight in the healthy kidney. They consist 
of (a) diverging blood-vessels, and (&) straight or collecting 
uriniferous tubules. The striations are prolonged into the 
cortex, where they are more prominent than in the pyramids, 
owing to the greater paleness of the epithelium. The red 
lines indicate the position of the blood-vessels, and the pale 
lines that of the uriniferous tubules, which, prolonged into 
the cortex, are known as the Pyramids of Ferrein, or medul- 
lary rays. 

These alternating colors are known as the markings of the 
cortex. If they are straight, the kidney is healthy or the 
lesion confined to the epithelia only ; if wavy or tortuous, 
a lesion involving the interstitial tissue is indicated, con- 
traction having caused the vessels to deviate from a straight 
course. 



26 



ANATOMY AND PHYSIOLOGY OF THE KIDNEYS. 



The Tissues which concern us are three in number, namely : 
i. The uriniferous tubules. 

2. The Malpighian tufts and blood-vessels. 

3. The intertubular structure (connective tissue, stroma). 
Synonyms. — In studying the anatomy of the kidneys we 

find several terms used synonymously. The most important 
are the following : 

Glomerulus. — The words tuft and Malpighian corpuscle 
are used synonymously with glomerulus. Some writers use 
the term Malpighian body or corpuscle, and confine the 




Fig. 6.— Shows a posterior view of the kidneys. The numbers represent the following: 
7, left kidney; 2, section of the right kidney; 3, cortical substance; 4, columns of Bertini 
5, pyramid of Malpighi; 6, vessels; 7, calyces; 8, pelvis; I7,_ aorta; 18. renal artery (left) 
19, inferiorvena cava; 21, renal cava (left); 22, renal vein (right). — Littre. 

term glomerulus to the capillary network within Bowman's 
capsule. 

Medtdlary Rays. — Also called pyramids of Ferrein, pyra- 
midal prolongations and lobules. 

Labyrinth. — The region of the convoluted tubules, also 
known as the Labyrinth of Ludwig. 

Bowmarts Capsule. — Also called Miiller's or the Malpig- 
hian capsule. 

Stellated Veins. — Stars of Verheyen. 



THE URINIFEROUS TUBULES. 27 

Convoluted Tubes of the First Order. — Proximal convoluted 
tubes. 

Convoluted Tubes of the Second Order. — Junctional tubes, 
intercalated tubes, distal convoluted tubes. 

Spiral Tubes. — Called also the spiral tubes of Schachowa. 

THE URINIFEROUS TUBULES. 

These begin in the cortical substance in small spherical 
bodies called Malpighian corpuscles (tufts, glomeruli), origin- 
ating in the capsules of the tufts opposite the site of the blood- 
vessels, and, after uniting, terminate, considerably reduced in 
number, at the papilla of the pyramid. They are essentially 
of two kinds, convoluted and straight. 

The capsule of the corpuscle (Bowman's capsule) becomes 
continuous with the tubules known as convoluted tubules of 
the first order, or proximal. 

Convoluted tubules. — At the juncture of the capsule with 
the tubule there is a slightly narrowed funnel-shaped neck, 
and, after repeated convolutions within the labyrinth, the 
tubule tends toward the medullary ray. Here it becomes 
(to varying depths) narrow, often exhibiting spiral windings 
before decreasing in calibre, and represents the descending 
branch of the loop, or Henle's tubule. This enters the pyra- 
midal substance, producing a distinct, angular divergence at 
the dividing zone between cortex and pyramid, in order to 
reach the bundles of the vasa recta. (See Blood-Vessels.) 
After reaching certain depths in the pyramidal substance, the 
narrow tubule produces a loop (the loop of Henle), and takes 
an upwatd course as the ascending branch of then arrow 
tubule, this being, on the whole, slightly wider than the de- 
scending portion. Again the ascending branch widens, with 
short, irregular curves and angles {the in r egular portion), and 
at the most peripheral part of the cortex, in which there ex- 
ist no tufts, it resumes the width and aspect of the convoluted 



28 ANATOMY AND PHYSIOLOGY OF THE KIDNEYS. 

tubule, being in this situation termed the convoluted tubule of 
the second order (distal convoluted tubule or the intercalated 
tubule}, which inosculates with the straight collecting tubule. 
By the union of several intercalated and collecting tubules 
arches are formed. Henle insists upon the arched arrange- 
ment of the collecting tubules themselves, to which the inter- 
calated tubules are joined. The collecting tubule occupies the 
centre of the medullary ray in the cortex. The groups of 
collecting tubes in the pyramid are situated between groups 
of the narrow tubules, decreasing in number, by continuous 
union at acute angles of analogous formations, until, lastly, a 
limited number of wide collecting tubules (eight to fifteen) 
open at the point of the pyramid — the papilla — which pro- 
trudes into the calyx. Their mouths are visible to the naked 
eye, and are called the foramina papiliaria. 

Fig. 7 shows the course and arrangement of the tubules. 

Summary. — The essential things to remember about the 
uriniferous tubules are the following : 
i. Bowman's capsule. 

2. The neck. 

3. The proximal convoluted tubules. 

4. The spiral portion. 

5. The descending limb of Henle's loop. 

6. The ascending limb of Henle's loop. 

7. The irregular tubules. 

8. The distal convoluted portion. 

9. The arched collecting tubules. 

10. The straight collecting tubules. 

11. The ducts of Bertini (wide collecting tubules). 
Situation of the Tubules. — The convoluted tubules of the 

first order occupy the portion around the ascending branches 
of the renal artery, and their sum total is termed the labyrinth 
of L/udwig. 

The convoluted tubules of the second order fill the most ex- 
ternal portion of the cortex, in which there are no tufts. 



DIAGRAM OF THE KIDNEY. 



29 




Fig. 7. — Diagram of the kidney. A, renal artery; V, renal vein; T, tuft; CT, capsule of 
tuft; AV, afferent vessel; EV, efferent vessel; CC, capillaries of convoluted tubules; CS, 
capillaries of straight tubules; B, arterial branch to the cortical substance; AP, arterial 
branch to the pyramidal substance; VR, vasa recta; CP, capillaries of the straight collect- 
ing tubules; L, capillaries of the papilla; CI, convoluted tubule of the first order; N, 
narrow or loop tubule; CH, convoluted tubule of the second order; S, straight collecting 
tubule in the medullary ray of the cortical substance; C, straight collecting tubule in the 
pyramidal substance; P, the same at the papilla.— (Heitzmann.) 



30 ANATOMY AND PHYSIOLOGY OF THE KIDNEYS. 

The straight tubules, both narrow (loop-tubules) and col- 
lecting, produce the medullary rays between the labyrinths 
in the cortex, while in the pyramids they run in separate 
bundles according to the following arrangement : First, the 
narrow tubules, together with the vasa recta (see Blood- 
vessels), in the imaginary prolongations of the labyrinth, 
and then the collecting tubules as direct prolongations of the 
medullary rays of the cortex. 

The labyrinth, the medullary rays, and medullary portion 
of the kidneys, contain the following, respectively : 

The Labyrinth contains : 

t. The Malpighian bodies. 

2. The constricted necks of the tubules. 

3. The proximal convoluted tubules. 

4. The irregular tubules. 

5. The distal convoluted tubules. 

6. The arched collecting tubules. 
The Medullary Ray contains : 

1. The spiral tubules. 

2. The ascending limbs. 

3. The straight collecting tubules. 
The Medulla of the Kidney contains : 

1. The descending limbs. 

2. The loops. 

3. The ascending limbs. 

4. The collecting tubules. 

Epithelium of the Tubules. — In a general way the epithe- 
lium is cuboidal in the convoluted tubules, flat in the narrow 
tubules, and columnar in the collecting tubules. 

In the polyhedral epithelia of the convoluted tubules is a 
rod-like structure (Rods of Heidenhain). The striations and 
rod-like markings are most prominent in the irregular 
tubules. 

Considered with reference to epithelia, we find the follow- 



EPITHELIUM OF THE TUBULES. 31 

Flat epithelia : capsule, neck, descending limb. 

Polyhedral epithelia : proximal convoluted tubules, spiral 
tubules, ascending limb, distal convoluted tubules. 

Very angular and markedly striated epithelia : irregular 
tubules. 

Columnar epithelia : straight collecting tubules. 

The polyhedral epithelia in the proximal convoluted tu- 
bules are somewhat triangular in character ; in the ascending 
limb cuboidal. 

Charles Heitzmann described the tubules and their epithe- 
lia as follows : 

"The convoluted tubules of the first order, having an 
average diameter of 0.0045 tnm., are lined by polyhedral epi- 
thelia, the cement-substance between them often being ill-de- 
fined, or, especially in the kidneys of children, absent. In 
these epithelia R. Heidenhain discovered a rod-like structure 
similar to that observed in the epithelia of the ducts of 
salivary glands. The ascending and descending portions of 
the narrow tubules have a diameter of 0.0020 to 0.0025 mm -, 
and are lined by cuboidal epithelia, which also exhibit the 
rod-like structure ; this peculiarity is particularly well marked 
in the irregular portions of the tubules. The descending por- 
tion gradually becomes narrow, and its epithelium passes by 
degrees into the flat variety, while the ascending portion often 
appears abruptly widened close above the loop, or in the 
depth of the loop itself. Along the course of the ascending 
tubule within the cortical substance the epithelium again 
may become flat, corresponding to a narrowing of the caliber. 
The narrow portions have a diameter of 0.0014 ; their caliber 
is comparatively wide, and the flat epithelia are finely 
granular and supplied with a distinct nucleus. In edge-view 
these epithelia appear spindle-shaped, closely resembling the 
endothelia of capillaries. The convoluted tubules of the 
second order have only a few convolutions ; their caliber is 
somewhat wider than that of the convoluted tubules of the 



32 



ANATOMY AND PHYSIOLOGY OF THE KIDNEYS. 



first order, their epithelia, however, being identical with 
those of the latter. In the irregularly- winding portions the 
epithelia show slight differences in their depths. The col- 
lecting tubules have the widest caliber, their diameter being, 
at the apex of the medullary ray, the same as that of the con- 
voluted tubules, while in their course toward the papilla they 
gradually assume a diameter of 0.020 to 0.030 mm. Their 
epithelia are at first cuboidal, but with increasing caliber the 



. Capsule. 

j Subcapsular layer of convoluted Jubu let 

Cortical labyrinths or regions of convoluted 
tubules 



Medullary rays or pyramids offerrein. 




j Cortex. 



j Medullary Pyramid. 



Fig. 8. — Diagrammatically exaggerated representation of the cut surface of a renculus 
(medullary pyramid and corresponding cortical arch). — (From Hektoen.) 



epithelia become distinctly columnar, being finely granular 
and obliquely arranged in the lower portions, after the man- 
ner of shingles on a roof. According to C. Ludwig, the mem- 
brana propria near the papillae is fused with the surrounding 
connective tissue. 



MALPIGHIAN TUFTS AND BLOOD-VESSELS. 33 

" All tubular formations of the kidney are ensheathed by 
delicate connective tissue, which carries the blood-vessels and 
nerves." 

Considered with reference to urine forming and urine con- 
ducting, we find the following : 

i. In the urine-forming tubes the epithelia have a well 
marked network, a delicate investing membrane, and are 
readily changed by disease. 

2. In the tubes through which the urine is conducted the 
epithelia have a less developed network, a firm investing mem- 
brane, and are less frequently affected by disease. 

THE MALPIGHIAN TUFTS AND BLOOD-VESSELS. 

Each uriniferous tube begins in a glomerulus (Malpighian 
corpuscle or tuft). 

The Malpighian corpuscles are small spherical bodies, regu- 
larly arranged in rows in the edges of the pyramids of Feirein 
in the cortical arches, and also irregularly scattered through- 
out the columns of Bertini. They vary from 0.25 mm. to 
0.32 mm. in diameter, and are composed (1) of a connective- 
tissue capsule^ rich in elastic fibres, lined with flat epithelia, 
and formed by an expansion of the basement membrane of 
the tubes, and (2) of a network of capillary vessels. The cap- 
sule is known as Bowman's, Miiller's, or the Malpighian, and 
is reflected over the glomerulus, and often dips in between the 
individual blood-vessels. 

The capillary network is formed by a small afferent artery 
(Fig. 9), piercing the capsule of Bowman and dividing into a 
number of convoluted loops, which unite to form an efferent 
vessel smaller than the afferent, and piercing the capsule very 
near the afferent. The capillaries differ from ordinary capil- 
laries in that their walls are thicker, they are not lined by a 
continuous layer of endothelium, and their outer surfaces are 
completely covered by a layer of flat epithelia. 

3 



34 



ANATOMY AND PHYSIOLOGY OF THE KIDNEYS. 



The convolutions of the capillary blood-vessels are arranged 
in two niain lobes ; hence the glomerulus is a bilobate forma- 
tion of capillaries. (Fig. 10.) 

The efferent vessel contains arterial blood, though the 
muscle-coat is very imperfect, or absent. 

Distribution of Blood-vessels. — The renal artery is the 
largest, in proportion to the size of the organ supplied, of any 




p IG- 9.— From the cortical portion of the human kidney, a, arterial twig giving off the 
afferent blood-vessel; {b) of the glomerulus (c* c')\ c, efferent vessel of the latter ; d, cap- 
sule of Bowman opening into a convoluted uriuiferous tube of the cortex «.-(Frey.) 

in the body. On entering the pelvis of the kidney it divides 
into several branches, which are termed arterise proprise 
renales. These traverse the columns of Bertini, supply in 
part the medullary pyramids and afferent vessels of the Mal- 
pighian bodies in that region, and divide at the base of the 
pyramids into two sets of branches for the further supply of 



MALPIGHIAN TUFTS AND BLOOD-VESSELS. 



35 



the kidney — namely, the interlobular arteries and the arte- 
riolar rectse. 

The interlobular arteries pass directly outward between the 
pyramids of Ferrein and terminate in the capillary network of 
the capsule. From these arteries are derived the afferent 
vessels of the glomeruli of the cortical portion. The arteri- 
olar rectse supply the medullary pyramids, whose substance 
they traverse, terminating at their apices. 




CT 



Fig. io.— Tuft from the kidney of a dog. Injected. T, capillary loops of the tuft, in 
connection with the afferent artery, covered by E, flat epithelia; Ca, capsule, covered 
with flat epithelia, in communication with Co, the convoluted tubule; CL, convoluted 
tubule in longitudinal section; CT, convoluted tubule in transverse section. Magnified 
350 diameters.— (Heitzmann.) 



The veins correspond to the arterial divisions. From the 
Malpighian corpuscle the efferent vessel divides into a net- 
work of capillaries, which surround the tubules of the cortical 
substance forming the intertubular plexuses, which, as they 
approach the cortex, form small veins. Those beneath the 
capsule are stellate in arrangement, and are called the stellated 



36 ANATOMY AND PHYSIOLOGY OF THE KIDNEYS. 

veins or Stars of Verheyen. They pass downward, receiving 
branches from the plexuses about the tubuli contorti, and at 
the bases of the Malpighian pyramids join the venae rectae, 
which are derived from the plexuses at the apices of the 
pyramids and from the venae propriae renales. The venae 
propriae renales accompany the arteriae propriae renales be- 
tween the pyramids, receiving in their course the efferent 
vessels from the glomeruli, and in the sinus of the kidney 
join with the veins from other pyramids to form the renal 
vein, which ultimately joins the inferior vena cava. 

All the arteries and veins interlace and completely sur- 
round the tubules. 

THE INTERTUBULAR TISSUE OR STROMA. 

This is made up of a variety of connective-tissue elements. 
The fibres are most numerous in the vicinity of the blood- 
vessels and around the Malpighian corpuscles. They are 
more marked in the cortical portion than in the medullary, 
but occur in abundance near the apices of the papillae. 

The capillaries of the glomeruli are covered with fine 
delicate connective tissue, and the capsule is completely 
enveloped in it. 

The loose connective tissue between the pyramids carries 
the larger blood- and lymph-vessels and the principal nerves. 

The blood-vessels and uriniferous tubes are held together 
by a delicate fibrous connective tissue rich in elastic sub- 
stance. 

The capsule of the kidney is of dense fibrous connective 
tissue. 

PHYSIOLOGY OF THE KIDNEYS, TOGETHER WITH CERTAIN 
PATHOLOGICAL CONSIDERATIONS. 

The normal functions of the kidneys are to remove from 
the body excrementitious substances and water. The most 



THEORIES OF SECRETION. 37 

important excrementitious substances are those containing 
nitrogen, as urea, uric acid and the urates. How this is done 
has been the subject of much investigation and discussion. 

Theories of Secretion. — There are two principal theories 
regarding the secretion of urine by the kidneys as follows : 

1. The Bowman-Heidenhain theory, according to which 
the secretion of urine is due to the activity of two sets of 
epithelia. The flat epithelia covering the glomeruli take 
up water and salts from the blood and transfer them to the 
beginning of the uriniferous tubules. Their activity chiefly 
depends on the activity of the circulation of the blood 
through the capillaries. But they may be also excited to 
active secretion by the presence of certain urinary constitu- 
ents in the blood, as water and salts, or possibly diuretics, 
like caffeine. The rodded cells of the convoluted tubules 
and ascending loop of Henle secrete specific urinary con- 
stituents, as urea and uric acid, and a certain amount of 
water; also certain abnormal constituents of the blood, as 
indigo-carmine. Their activity depends on the amount of 
urea and uric acid in the blood. 

II. The modified Ludwig theory, which holds that the 
secretion of urine is a mixture of physical and physiological 
processes. In the glomerulus a physical process takes place, 
namely, a transudation of watery and crystalloid constituents 
(including urea) of the blood plasma. The extent and nature 
of this transudation is determined : 

i. By the pressure in the capillaries of the glomerulus. 

2. By the velocity of the flow through the capillaries. 

3. By the permeability of the capillary wall and the 
glomerular epithelium. 

This watery transudate is concentrated and altered on its 
way through the tubules in consequence of absorption of 
water, and probably of certain of its crystalloid constituents. 
This absorption must be due to the active intervention of the 
epithelia, since the osmotic pressure of the urine is consider- 
ably higher than that of the blood-pressure. 



38 ANATOMY AND PHYSIOLOGY OF THE KIDNEYS. 

Diuretics may act in two ways. Salines increase the press- 
ure and velocity of the blood in (?) the glomerular capsules, 
not only by increasing the volume of the circulating fluid, 
but also, probably, by direct dilator action on the afferent 
vessels of the glomerulus. Caffeine and theobromine have 
this action, and probably also paralyze the absorbing mechan- 
ism of the kidneys, that is, the epithelia of the convoluted 
tubules, so that the glomerular transudate may undergo little 
change in its way to the ureters and bladder. 

Influence of the Nervous System. — This distribution of 
nerve-endings to the tubules suggests the possibility that the 
central nervous system may control the secretion of urine 
directly apart from its influence on the renal circulation. 

Important Parts of the Kidneys. — These, from a patho- 
logical standpoint, are the capsules, including the fat capsule 
(tunica adiposa), the tubules, the glomeruli, the blood-vessels 
and the interstitial tissue, the pelvis and calyces. 

PATHOLOGICAL CLASSIFICATION. 

The kidney is subject to the following morbid changes : 
Malformations, malpositions, hypertrophy, atrophy, anemia, 
hyperemia, hemorrhage, thrombus, embolism, calcareous infil- 
tration, uratic infiltration, argyrosis, biliary pigmentation, 
hemoglobin pigmentation, glycogenic infiltration, dropsical 
infiltration, leukemic infiltration, cloudy swelling or paren- 
chymatous degeneration, fatty changes, amyloid degen- 
eration, hyaline degeneration, inflammations (nephritis), 
together with the functional and organic disturbances result- 
ing from them, tuberculosis, syphilis, leprosy, glanders, 
actinomycosis, tumors, cysts, and parasites. 

The fat capsule is often the seat of abscess. 

The fibrous capsule, normally easily separated, becomes 
strongly adherent in certain lesions, notably chronic inter- 
stitial nephritis. 



MORBID CHANGES. 39 

The tubes and glomeruli become the seat of inflammation 
or degeneration in the various forms of nephritis. 

The arteries are very often changed by disease. There is 
either thickening of one or of all of their coats, or they are 
the seat of waxy degeneration. 

The interstitial tissue is often infiltrated with cells, or ir- 
regularly thickened by a new growth of connective tissue. 

The pelves and calyces are lined with mucous membrane 
which may become inflamed, and they themselves may be 
dilated. 

Disturbances of the Functions of the Kidneys. — These are 
brought about by : 

i. Rapid or slow changes in the tissues of the kidneys. 

2. Changes in the quantity,, the composition, and the 
rapidity of circulation of the blood. 

3. Nervous influences affecting the quantity of the urine. 

4. Diseases of the urethra, bladder, ureters, and pelves of 
the kidneys. 

5. Diseases of the lungs, heart, liver, stomach and intes- 
tines. 



CHAPTER II. 

PHYSICAL EXAMINATION OF THE KIDNEYS. 

Inspection. — This will show a large tumor of the kidneys, 
particularly in the case of enormous cystic kidneys. In such 
cases the growth may fill one or the other lumbar region and 
the corresponding portion of the umbilical region. There 
will be bulging outward of the ribs on the affected side. 
The tumors which are most likely to be detected in addition 
to cystic kidneys are sarcoma in children, hydronephrosis, 
and paranephric abscess, the latter posteriorly. 

In a case of enormous cystic: kidneys which the writer saw 
the bulging was easily detected by inspection even when the 
patient was lying flat on his back. 

A normal movable kidney is not perceptible upon anterior 
inspection. 

Palpation. — The bowels should be moved thoroughly be- 
forehand, either by cathartics or by a high enema. The 
patient is placed in the dorsal recumbent position with head 
and chest slightly raised, and the legs and thighs flexed. 
Breathing being natural, during respirations push the right 
hand in the direction of the lumbar region, while firm pressure 
is made with the left against the lumbar region. If the kid- 
ney is enlarged it will be felt during inspiration between the 
two hands. If the attempt is unsuccessful, put the patient 
on the opposite side and try again. In some cases success 
may be achieved when the patient is sitting or standing. 
(Senn.) 

In cases of renal tuberculosis complicated by paranephric 
abscess there is well-marked swelling, which is fixed, and 
fluctuation can be made out by palpation. 



PALPATION. 



41 



Practically a kidney which is palpable is either movable or 
enlarged. 

Lapthorn Smith advocates the invariable use of the semi- 
erect posture of the patient in examining for floating kidney. 
The patient should stand, leaning slightly forward, with her 




Fig. ii. — Showing nine topographical areas of abdomen. (After Joessel. Redrawn 
and modified by Butler.) 

hands on the back of a chair, so as to relax the abdominal 
muscles, while the examiner sits to the right and a little 
behind. 

In some cases the knee-elbow position is the best for dis- 
covery of movable kidney. 



42 PHYSICAL EXAMINATION OF THE KIDNEYS. 

We distinguish (i) palpable kidney — one which is normal 
in size and position, the lower border of which can be felt 
when the abdominal walls are not too thick. (2) Movable 
kidney — one which can be felt to slip down so that its entire 
length can be felt, especially if it can be pushed down to the 
horizontal umbilical line, an.d (3) floating kidney — one which 
can be displaced into the lower half of the abdomen, pushed 
across the median line, or displaced in any direction. 

Enlargement of the kidney may be detected by palpation 
anteriorly. In some instances the renal artery may be felt 
pulsating if the kidney can be seized. (Butler). 

The normal kidney is felt as a smooth, oval, and half- 
elastic organ ; in the case of growths it may feel smooth, soft, 
fluctuant, dense, uneven, globular, or lobulated. 

The kidneys cannot always be palpated ; they are best 
made out in the case of thin persons with flabby abdominal 
walls. 

In the male the kidney can only exceptionally be felt ; in 
woman the normal left kidney may be palpated in about 30 
per cent, of the cases, the right in 75 to 80 per cent. 

It should not.be forgotten that the kidneys lie behind the 
peritonaeum, and that they may or may not move with 
respiration. 

Percussion. — The patient should lie upon the abdomen 
across a rather hard pillow. Anteriorly percussion reveals 
little or nothing. 

Posteriorly only the outer and lower margins can be made 
out, on account of the proximity of the neighboring organs- 
This border is found about 10 centimetres (four inches) from 
the spinous processes, but only when the colon is filled with 
gas ; if full of faeces or over-distended with gas the attempt to 
percuss the outer border will be futile. 

The area of kidney dullness is between the twelfth rib and 
the crest of the ilium. The space is about 5 centimetres 
(two inches) broad, and it must be percussed sharply in order 
to be appreciated. 



percussion: rectal insufflation. 43 

Anteriorly the dullness is abruptly exchanged for tympan- 
itic resonance as the intestines are approached. 

Percussion is chiefly of service in two conditions : First, 
when the kidney is absent or dislocated ; and, second, in large 
renal tumors. In the latter case a broad tympanitic strip will 
be found to run along the posterior or lateral portion of the 
tumor from adhesion of the ascending or descending colon. 
The dullness usually extends over the surface of the thorax. 

If percussion dullness is increased, enlargement of the 
kidney is to be suspected ; if decreased or absent, movable 
kidney. 

Auscultatory Percussion. — By use of the phonendoscope 
(which is placed over the centre of the kidney or the tumor) 
and very gentle tapping of the abdominal wall with the 
finger-tips in a radiating direction from the instrument the 
outline of the body on which the phonendoscope rests can be 
made out with great precision by the impulse and pitch of the 
note conveyed to the ear. 

Anterior auscultatory percussion as above is useful for con- 
firmatory evidence in cases of tumors revealed by palpation. 

Tenderness on Pressure. — This characteristic is of value in 
the diagnosis of the following conditions : 

i. Acute nephritis. Paranephritis, especially noticeable. 

2. Renal calculus, especially if inflammation result from it. 

3. Hydronephrosis (usually). 

4. Suppurative nephritis. 

5. The writer found it in one case of renal hsematuria in a 
hemophilic patient. (Diagnosis verified by operation). 

Rectal Insufflation. — Procure a large rubber bag .capable of 
holding four gallons of air, connect it with rubber tubing four 
to six feet long, and have a stop-cock near the bag itself- 
To the further end of the tubing attach the tip of an ordi- 
nary vaginal syringe, being careful to fasten it on securely. 
The patient assumes the dorsal recumbent position. The tip 
is inserted into the rectum, and one assistant presses the 



44 



PHYSICAL EXAMINATION OF THE KIDNEYS. 



margins of the anus against the rectal tube to prevent the air 
from escaping. Another assistant sits on the bag rilled with 
air and placed on a chair, and turns on the stop-cock. The 
inflation is to be made very slowly and without interruption. 
The hands being placed over the sigmoid flexure, it is possible 
to feel the entrance of the air into the bowel. Continue the 
inflation until the caecum is well distended. 

Dulness having been outlined beforehand by percussion, the 
difference caused by inflation may be ascertained by repeating 
the percussion after inflation. 




\ Spleen! 
>§pieni( 

htkidjiey Mesentery Lef 1 kidn ^ 
cendimji Descending" 



Great* omentum 
Small inHSsHnes 



colon 

Smafl 
sntesHn 



S*tgmoid7 
flexure 





Fig. 12.— Showing roughly the contents of the nine topographical areas of the abdo- 
men. (Butler.) 



If the dulness disappears entirely after inflation the swelling 
is retro-peritoneal ; if the dulness only partly disappears the 
tumor is intra-abdominal. 

In this way an enlarged spleen may be differentiated from 
a tumor in the left renal region ; if the colon be inflated and 
found to be in front of the tumor, the latter is renal and not 
splenic. 

Inflation of the colon is often advisable for diagnostic pur- 



LARGE FORMATIONS. 45 

poses, since the kidney, when enlarged by growths, usually 
pushes before it the ascending or descending colon against the 
anterior abdominal wall, which furnishes a tympanitic note. 

Physical Signs Furnished by Pathological Conditions. — 
A number of pathological conditions furnish certain physical 
signs of significance as follows : 

Paranephritis with Paranephric Abscess. — A circular sym- 
metrical swelling between the borders of the ribs and the brim 
of the pelvis, extending posteriorly toward the spine, with 
cedematous condition of the skin and tissues beneath it and 
tenderness on pressure. 

Movable Kidney. — Palpation reveals movable kidney by its 
form, mobility, size, capability often of replacement, and occa- 
sional pulsation of the renal artery. 

Movable left kidney is differentiated from movable spleen 
by palpation and percussion. Palpation reveals characteristic 
notches in the spleen, but pulsations of the renal artery by 
deep pressure at the hilum in the kidney. 

Large Formations. — Carcinoma, sarcoma, hydronephrosis, 
pyonephrosis, paranephritis and echinococcus may be all 
plainly palpable. Likewise cystic kidneys. 

The tumors of hydronephrosis, pyonephrosis and echi- 
nococcus are large, rounded, globular and sometimes fluctuat- 
ing. L,arge cystic kidneys can be felt as rounded masses ; 
malignant tumors may be so large as to fill one -half the abdo- 
men. They may be somewhat movable, and if of rapid 
growth a sense of fluctuation may be apparent. 

Paranephric abscess shows distinct evidence in some cases 
of a tumor, in others a bagginess or induration in the interval 
between the last rib and the crest of the ilium, tending to 
bulge backward and become palpable posteriorly. 

In some cases of the above large formations it may merely 
be evident that the kidney is enlarged, or that there is an 
obscure swelling or sense of resistance anteriorly, or a bulging 
and indistinct swelling posteriorly. 



46 PHYSICAL EXAMINATION OF THE KIDNEYS. 

Echinococcus. — A peculiar whiz known as the hydatid 
vibration is shown by quick, short, bimanual percussion 
strokes. 

Respiratory Mobility. — As the kidneys move but slightly 
with respiration, pronounced respiratory mobility, as a rule, 
excludes the kidney. 

Capability of Replacement. — If the tumor is capable of 
replacement so that it disappears, it is thus proved to be renal. 

Differential Diagnosis Between Renal Tumors and Those 
of Other Organs. — Renal tumors, according to Stiller, present 
the following characters : 

i. Unilateral occupation of abdomen. 

2. Spherical contour. 

3. Downward growth. (Palpation reveals lower margin.) 

4. Absence of any influence of the rhythmical movements 
of the diaphragm in breathing, when the tumor is fixed 
against the abdomen. 

5. Relation to intestines : intestines lie over small tumors ; 
in larger ones, are pushed toward median side. 

6. Presence or absence of tympany depending on amount 
of intestine covering the tumor. 

7. Bulging posteriorly. 



CHAPTER III. 

GENERAL CLINICAL FEATURES OF RENAL DISEASES. 

Before considering the various renal diseases in detail, at- 
tention must be paid to the general clinical features of patients 
suffering from disorders affecting the kidneys. Inasmuch as 
in some cases the condition of the urine is the most salient 
feature, we shall consider this first. 

The Urine in Renal Diseases.— One of the most significant 
changes in the urine when kidney disease is present is an 
unaccountable alteration of the ratio of day urine to night. 
Normally this ratio is three or more to one. In many cases 
of renal disease, however, the patient voids nearly as much 
urine after going to bed as during the entire time he is up, 
In severe cases of nephritis more urine may be voided during 
the night than during the day. 

Alterations in the quantity of urine for the 24 hours are 
common. The patient with renal disease is likely to pass too 
much or too little urine. The color is likely to be too light 
or too dark. The specific gravity is likely to be too high or 
too low. It is seldom that we find in a well-marked case of 
renal disease urine normal in day and night quantity, ap- 
pearance, color, odor and specific gravity. In the few cases, 
however, when the above physical characteristics are normal, 
the finding of albumin and tube-casts will reveal the presence 
of the disorder. A suspicious sign also is the unaccountable 
voiding of scanty urine of pale or light color. Normally, 
when the urine is deficient in quantity the color should be 
deeper in tint; in many cases of nephritis a decrease in the 
quantity of 24 hours' urine is attended by a hardly perceptible 
change in the color. It goes without saying that light-colored 
urine which foams abundantly is likely to contain albumin. 



48 CLINICAL FEATURES OF RENAL DISEASES. 

A patient who voids alternately large and small quantities 
of urine should have his attention called to the possibility of 
the presence of renal lesion, even if no other significant symp- 
toms are present. Women with hydronephrosis may show it 
only by this alternation in the quantity of urine. Cases of 
hysteria, of course, present an exception. 

The finding of blood, pus, and crystals in the urine is often 
indicative of some malady of the kindeys, though in many 
diseases elsewhere in the urinary tract we may encounter these 
constituents. 

The relation of albuminuria to diseases of the kidneys is 
here to be considered. It may be said in general that albu- 
minuria, however slight, if not due to the presence in the 
urine of pus, blood, leucorrhceal, seminal or prostatic fluid 
must be considered a sign of renal disease. The disease may 
be latent, and not evident in other ways. The writer has, 
however, observed the presence of albumin in the urine in 
the case of young men after sexual excitement. It may, in 
these cases, possibly be due to admixture of prostatic fluid or 
be referable to slight congestion of the kidneys. The urine 
contains numerous mucous casts and bands, but no genuine 
casts, and is otherwise normal. 

Children frequently have an albuminuria without casts 
which disappears as they grow older. I cannot recall any 
case of this kind, without casts in the urine, which has since 
developed into a nephritis without other known cause. 

Senator insists that albumin occurs physiologically in the 
urine. This may be true in the case of children, but in the 
writer's experience many otherwise unaccountable albumin- 
urias are referable to prolonged sexual excitement, and it is a 
significant fact that the so-called physiological albuminuria is 
especially noticeable in the young. 

It is quite common among unmarried men who are addicted 
to sexual excess or subjected to sexual excitement. 

Those who believe in physiological albuminuria classify it 
as follows : 



PHYSIOLOGICAL ALBUMINURIA. 49 

Dietetic (following ingestion of certain kinds of food, as 
cheese, eggs, pastry), after exertion (severe and prolonged), 
and simple persistent, without other symptoms or known 
cause. 

It is possible that a mistake has been made by some who 
rely on the so-called " delicate " tests for albumin which the 
writer has shown to react with alkaline carbonates in the 
urine. Even trichloracetic acid gives a ring with urines free 
from albumin, but containing alkaline carbonates in abund- 
ance. Proof of this can be had by adding strong solution of 
calcium chloride, filtering, and noticing absence of the ring 
after filtration. 

In one case in which albumin was undoubtedly present in 
the otherwise normal urine of a young man, the writer was 
urged by a life insurance agent " to break the news " to the 
patient's family. It was ascertained, however, that the young 
man was engaged to be married, on the strength of which in- 
formation the writer refused to alarm the family. Not long 
afterward the patient married and since then albumin has dis- 
appeared. Ten years have failed to demonstrate the existence 
of nephritis in this case, the individual in question being still 
alive and in good health. 

P. Bdel {Munch. Med. JVoch.) has carefully observed the 
phases of cyclical albuminuria in three cases and from the 
study of these cases has drawn certain conclusions : The 
patients all presented the same clinical picture of nervous, 
weakly, non-resistent body habit, without any organic lesion 
save that producing the albuminuria, which varied according 
to the position (standing and lying), and had its maximum 
intensity during the forenoon. He found that after the " mid- 
day " dinner (taken at various hours) the albuminuria disap- 
peared, to reappear again in the evening. He caused the 
meal to be passed over, and no diminution of the albuminuria 
took place. He next employed a diuretic (Potassium acetate), 
and observed the effect in conjunction with fasting. The 
4 



50 CLINICAL FEATURES IN RENAL DISEASES. 

urine became alkaline and free from albumin. The quantity 
of urine appeared to have a direct connection with the pres- 
ence or absence of albumin. In free diuresis the urine was 
pale, and there was no albumin, while when the urine was 
sparse the color was dark, and albumin was found usually up 
to 0.4 per cent. The effect of hot baths was relatively the 
same. Turning his attention to the pulse, he found that in 
the morning, while the patients were getting up, and es- 
pecially during washing, the pulse was very small, but this 
change was not to be noted during the same movements in the 
afternoon or evening. The pulse volume, representing the 
amount of resistance in the arteries, was directly in propor- 
tion to the amount of albumin secreted at the time by the kid- 
neys. Turning this to therapeutic use, he watched the effect 
of inarching, in soldierly fashion, up hill, and even up 
mountain. Carrying this out, short of fatigue, he succeeded 
in producing a secretion of pale urine, free from albumin. 
The rationale of this treatment lay in the calling forth of sys- 
tematic exercise on the part of the heart. He obtained good 
results when he ordered a very nourishing and sustaining diet 
in concert with mountain climbing, and claims that after a 
time these results were permanent. In connection with this 
subject, he mentions that the same procedure has proved 
beneficial in certain cases of true nephritis, although he adds 
that he has only been able to observe the effect during a 
relatively short period. {New Albany Medical Journal.) 

Patients who have albuminuria should avoid asparagus, 
strong tea and coffee, sharp spices and acids. 

The case is, however, far more significant and serious when 
tube-casts either with or without albumin are found. Dili- 
gent search may reveal occasionally a small hyaline cast or 
two in the urine otherwise normal and in the individual 
really healthy. When, however, half a dozen casts of any 
kind or of different kinds can be found in half a fluid ounce 
of urine, the chances are greatly in favor of the existence of 



THE PATIENT IN RENAL DISEASES. 51 

some kind of renal disease, especially if at the same time 
there is albuminuria, however slight, and still more so if the 
ratio of day to night urine or the physical characteristics of 
the urine are unaccountably abnormal. 

A trace of albumin and a few tube-casts in the urine of men 
over fifty years of age may, however, be present for years 
without interfering with the health or comfort of the indi- 
viduals concerned, as shown by Osier. But when in addition 
we find decrease in the ratio of day urine to night, persistent 
low specific gravity of the urine together with cardio- vascular 
or retinal changes then the condition becomes serious. 

The Patient in Renal Diseases. — We must next consider 
the features other than urinary presented by the patient with 
kidney disease. 

We find various physical characteristics of the individual : 
Those of the uric acid diathesis and its liability to renal 
changes are a robust, well-developed body, florid face, thick 
hair, good teeth, hearty appetite, good digestion and strong 
heart with high-pressured arteries ; a waxy pallor on the 
other hand is common in various forms of nephritis ; cyanosis 
is observed in some cases of chronic renal congestion ; slight 
jaundice or sallowness of the skin may be observed in waxy 
degeneration of the kidneys ; a peculiar light fawn color to 
the skin has been noticed by the writer in several cases of 
contracting kidney. 

The pulse is often significant in cases of renal disease when 
attended by cardio-vascular changes ; for example, the slow, 
tense pulse in contracting kidney, the rapid feeble arythmic 
pulse in cases where the heart is dilated. In mild, slow cases 
of contracting kidney the pulse is often slightly arythmic, 
but not noticeably tense. Loss of muscular strength is often 
the only feature complained of by patients in the early stages 
of chronic renal disease. Extreme weakness, pallor, edema, 
or general anasarca and difficulty of breathing are well- 
known symptoms of severe renal disease. 



52 CLINICAL FEATURES IN RENAL DISEASES. 

In some cases dizziness or vertigo may be the first note- 
worthy features. Headache is of prime importance as a 
symptom, especially when occipital. 

The various forms of Bright's disease present, when ad- 
vanced, very characteristic physiognomies : those of acute 
Brighfs and chronic non-indurative, formerly called paren- 
chymatous, nephritis being often quite pathognomonic. 

In early stages, the patient may appear above more than be- 
low proper standard of health; as the disease advances char- 
acteristic pufrmess of eyelids appears. This puffiness is ex- 
tremely important and suggestive when encountered in a man 
under 60 years. It varies greatly at different times of the 
day. In early morning eyelids may be distinctly dense, 
somewhat paler than remainder of countenance, may show 
a certain curious translucency. A.s the day advances lids be- 
come more baggy, but by afternoon or evening this will have 
disappeared and the thin skin have fallen into fine deep 
wrinkles. 

In interstitial nephritis, marked edema is not to be ex- 
pected early in the disease. When it does occur it is usually 
secondary to cardiac weakness and presents features of the 
edema of heart disease. 

Vomiting is noticed with surprising frequency in cases of 
injury or disease of the kidneys ; g astro-intestinal disturbances 
in general may be the most marked features in a given renal 
case. 



CHAPTER IV. 

ANOMALIES OF THE KIDNEYS. 

WE distinguish the following anomalies : 
I. Anomalies of position. 2. Anomalies of form. 3. 
Anomalies of size. 4. Anomalies of number. 

1. Anomalies of Position. 

These are three in number, namely : 
i. Fixed. 2. Movable. 3. Floating. 

Fixed Misplacements. 

These are either congenital or acquired. The congenital 
displacement is more frequent in men than in women, and af- 
fects more commonly the left kidney, being associated with an 
abnormal arrangement of renal vessels, ureter, and large in- 
testine. The kidney is not only misplaced but frequently 
misshapen, and the suprarenal capsule only occasionally ac- 
companies it, more frequently remaining in its natural po- 
sition. 

The presence, however, in the renal substance of aberrant 
portions of suprarenal tissue is a malformation of great im- 
portance, as it is not rarely the starting point of renal tumors. 

Cases have been known to occur in which one kidney has 
been found over the sacro-iliac synchondrosis, between the 
bifurcation of the abdominal aorta, or in the hollow of the 
sacrum. 

The two kidneys have been found on the same side, in 
which case they are usually located lower than the normal. 

Acquired misplacements result from various causes, among 
which we find : 



54 ANOMALIES OF THE KIDNEYS. 

i. Pressure from a tumor or an enlarged neighboring or- 
gan. 

2. Tight lacing. 

3. Sudden blows or jar, with subsequent inflammatory ad- 
hesions. 

The other two misplacements (movable and floating) may 
be grouped under the heading 

Wandering Kidneys. 

We distinguish two classes : 

1. Movable : often very painful, and a source of great irri- 
tation. 

2. Floating : often congenital, and one which may or may 
not give rise to symptoms. 

Movable kidney is fifty times as common as floating kid- 
ney, but both may exist in the same person. The right kid- 
ney is much oftener displaced than the left. 

Synonyms. — Floating kidney, movable kidney, nephrop- 
tosis, ren mobilis. 

Dystopia of the kidney is the term used for an unmov- 
able displacement of the organs which is usually on the left 
side. 

Etiology. — Movable kidney is commonly due to the follow- 
ing causes : 

1. Distention and relaxation of the abdominal walls as a re- 
sult of pregnancy. 

2. The influence of clothing as tight waist bands and 
corsets. 

3. General enteroptosis of which it is a part : gastroptosis, 
coloptosis, and corset liver may be associated with uterine 
displacement. 

4. Congenital predisposition and nervous influences as in 
diseases of the generative organs in women. 

Other and probably less important causes which have been 
assigned are the following : 



ETIOLOGY OF MOVABLE KIDNEY. 55 

Trauma involving the region of the kidneys, emaciation 
with loss of perirenal fat, diseases of neighboring organs, 
severe physical labor with frequent tension of the abdominal 
muscles ; childbirth with its accidents ; spinal curvature ; 
alterations in intra-abdominal pressure ; tumors of the liver, 
spleen, or pancreas ; effusions ; mal-assimilation and imper- 
fect development. Increased weight of the kidney from can- 
cer or tuberculosis may cause it. It is found in women who 
have tabes dorsalis. 

Movable kidney frequently occurs in women who do not 
wear corsets at all. 

According to M. L/. Harris the usually mentioned etiologic 
factors of movable kidney have little or no influence. The 
essential cause lies in a particular body form. Reliable 
results are obtained by dividing the jugulo-symphysis distance 
by the abdominal circumference at the level of the lowest 
point of the tenth rib. A more accurate index still is ob- 
tained by dividing the lateral diameter of the lower plane by 
that of the upper plane bounding the middle zone of the 
body cavity. The chief characteristic of this body form 
is marked contraction of the lower end of the middle zone 
with lessened capacity. This depresses the kidney so that the 
constricted outlet comes above the center of the organ and all 
acts, as coughing, lifting, etc., which adduct the lower ribs, 
press on the upper pole and crowd it still further downward. 
Repetition of these internal traumas gradually produces mov- 
able kidney. It is never the immediate result of external 
trauma. 

Movable kidney is due to increased laxity of its attach- 
ments, in turn due to a diminution in the amount of fat sur- 
rounding it, or to detachment of the peritonaeum from the 
muscle. We find several classes of cases : 

i. Those in which the fat capsule is large and loose, allow- 
ing movements of the kidney within it. 

2. Those in which the fat capsule closely surrounds the 
kidney and moves with it. 



56 ANOMALIES OF THE KIDNEYS. 

3. Those in which the kidney moves within the fat cap- 
sule, and the capsule also moves about with the kidney 
behind the peritonaeum. 

The degree of mobility varies considerably and is always 
limited by the length of the renal vessels. 

Floating kidney, on the other hand, depends on an irregu- 
larity of the disposition of the peritonaeum (a fold of this 
membrane completely enveloping the kidney so as to form a 
mesonephros, allowing the organ to float about in the abdom- 
inal cavity in any direction), or else on some abnormal ar- 
rangement associated with malposition of the colon, the kid- 
ney being left unsupported and free to move between diverg- 
ing processes of the peritonaeum. 

The kidney may fall below the brim of the pelvis, or as far 
forward as the anterior abdominal parietes, or across to the 
opposite side of the spinal column. A case is on record in 
which the kidney moved under the peritonaeum, through a 
space described, as a circle, with a diameter of eight or nine 
inches. 

Occurrence. — It occurs 'more commonly in women and espe- 
cially in women who have had children, usually between the 
ages of twenty and fifty. - It may occur in young women of 
the chlorotic type in combination with nervous, digestive and 
nutritive disturbances. Children and infants are not exempt 
from it. 

The right kidney is more often affected because it is less 
firmly fastened, placed lower and affected by the great mass 
of liver above it. 

Onset. — It may appear suddenly, but the majority of cases 
require months or even years for full development. 

Clinical History. — There is usually a history of severe 
physical labor with frequent tension of the abdominal muscles 
in women who have borne children, or of a severe wrench or 
lumbar strain. Cases have been known to develop after sea 
voyages where the patient has vomited and lost flesh from 
sea sickness or become emaciated from other causes. 



PHYSICAL EXAMINATION FOR MOVABLE KIDNEY. O ( 

Physical Examination. — The kidney is deficient in its 
proper means of fixity and must be deemed abnormally mov- 
able under any of the following conditions : 

i. When the whole kidney descends during deep inspira- 
tion below the examiner's fingers on deep palpation. 2. When 
the greater part of the kidney so descends as to be felt between 
the two hands. 3. When the lower half of the organ so de- 
scends, and can be so felt. In the cases in the third group, 
and in some of those in the second, the organ can not be 
retained between the fingers, but slips back again on expira- 
tion. 4. When the kidney is out of position during natural 
respiration, and may be easily felt. This constitutes the so- 
called "floating kidney." 5. When the kidney moves hori- 
zontally, upon the plane of the posterior parietes, and does 
not drop forward or inward. (Morris). 

Goelet believes that the examination for the detection of a 
prolapsed (movable) kidney should be made with the patient 
standing and with the body inclined slightly forward so as to 
relax the abdominal muscles. The examiner sits in front and 
a little to the right of the patient, grasps the right loin with 
his left hand, with the four fingers behind the right lumbar 
region and the thumb in front just below the border of the 
ribs. The patient is now directed to take several deep in- 
spirations and to expire to the extreme limit. When expira- 
tion is complete he presses the thumb well into the abdominal 
wall under the ribs, depressing it as much as possible so as to 
reduce the space between it and the fingers posteriorly. If 
the kidney is out of position, it must be below his thumb, and 
he can feel the kidney slip into position as it is pushed up- 
ward by the fingers of the right hand. His observations have 
led to the following conclusions, viz.: (1) That prolapsed 
kidney is more frequent than is generally supposed ; (2) that 
it is often not suspected, because it does not always give rise 
to symptoms directly referable to the kidney ; (3) that fre- 
quently it is not discovered because, by the usual methods of 



58 ANOMALIES OF THE KIDNEYS. 

examination, only an expert can detect it unless the kidney 
is much enlarged or the subject is thin and the abdominal wall 
relaxed. 

Cardinal Symptoms. — There may be no symptoms at all in 
the case of movable kidney, but the most common feature is 
pain more or less local, but often radiating into the epigastric, 
sacral, or lumbar region, nsually dull and dragging, but at 
times, and especially during the menstrual period, colicky. 
The pain is not rarely associated with nausea. 

Clinical Features. — In general we find in the earlier stages 
the following : 

i. Digestive disturbances. Common in nearly all cases, 
including constipation. 

2. General nervousness, and serious mental anxiety. 

3. Epigastric pain to the left of the median line. 

4. Cardiac palpitation. 

5. Inability to sleep or to be comfortable on the left side. 
In later stages as follows : pain prominent, due to chronic 

localized peritonitis or neuralgia of the lumbo-abdominal 
nerves; anorexia, nausea, sometimes vomiting, vertigo, anaemia, 
menstrual disturbances, occasionally renal or uterine haemor- 
rhages, despondency, occasionally icterus, and attacks like 
renal or biliary colic. Vomiting may occur without pains 
or nervous symptoms. A dislocated organ is extremely irri- 
table, and the reflex and symptomatic phenomena are chiefly 
due to this irritation. 

Movable kidney greatly aggravates a gouty condition. 

Clinically we may classify the symptoms as (1) painful ; 
(2) dyspeptic ; (3) neurasthenic. The pain is aggravated by 
motion, or by riding and driving. During rest it becomes 
slight or entirely disappears. Periodically, as above stated, 
the attacks of colic (Dietl's crises) occur. There is an onset 
of violent pain with chilliness, slight fever, great tenderness 
and tension of the abdomen, vomiting, and collapse. 

The pain is caused by torsion or bending of the ureter, and 



CLINICAL FEATURES OF MOVABLE KIDNEY. 59 

the latter leads to an acute hydronephrosis, or even to a 
chronic condition of this sort, and secondary pyelitis. 

The patient will generally complain of a " dragging " sen- 
sation on the affected side. 

The kidney is most readily found to be movable by catch- 
ing it during a deep inspiration and palpation with deep press- 
ure will make the patient complain of nausea or of a 
deathly faint feeling. 

Since gall-stones are common in women with enteroptosis 
and corset liver, it may be possible to find the kidney movable 
during attacks of biliary colic, but intestinal obstruction and 
jaundice due to it are rare. When there are hepatic symp- 
toms the latter are exceedingly intractable. 

This is so much the case that when a patient has severe 
hepatic symptoms, short of jaundice, and the ailments do not 
yield to ordinary treatment, one should at once suspect that 
the hepatic condition is being continued by the reflex disturb- 
ance of a mobile and displaced kidney, and all efforts should 
be redoubled to detect it. Unless the kidney is kept in posi- 
tion by a belt, or (in condition of excessive mobility) by 
operation, the attacks will recur. 

A peculiar symptom, and one said to be quite diagnostic, is 
that women who have borne children state that they experi- 
ence less trouble during the latter half of pregnancy than at 
any other time, and have rapid return of the pain and distress 
soon after the child is born. 

Hematuria is rarely noticed in movable kidney. In one 
case reported by A. T. Cabot severe threatening hematuria 
occurred which was finally controlled by nephropexy. 

Causes of the Pain and Disturbances. — The dilatation of 
the stomach is attributed to direct pressure of the kidney on 
the pylorus or duodenum. The hydronephrosis and pyo- 
nephrosis may be produced by a twist of the ureter. The at- 
tacks of abdominal pain, etc., collapse, chills, fever, and the 
like, with scanty and possibly bloody urine, have been 



60 ANOMALIES OF THE KIDNEYS. 

attributed (i) to circumscribed peritonitis from an incarcera- 
tion of the kidney in the peritonaeum surrounding it ; (2) to 
acute hydronephrosis from compression or twist of the ureter ; 
(3) a disturbance of circulation in the kidney caused by 
obstruction of the renal vessels, especially the vein, in conse- 
quence of a displacement or twist of the movable or floating- 
kidney. 

Effects. — These are dilatation of the stomach (rarely pro- 
lapse of the stomach), gall-stones, due to partial obstruction of 
the common duct by the pedicle; hydronephrosis, death from 
complete strangulation due to torsion of the vessels and 
ureter, and a condition simulating aneurism by dragging on 
the abdominal aorta and kinking of the vena cava. Chronic 
appendicitis may be dependent on movable right kidney. 

The mental state is one of irritation, despondency, chagrin, 
and melancholy over inability to work. Death from these 
and digestive disturbances occasionally takes place. 

Clinically we find the most frequent effect of movable 
kidney to be hydronephrosis, either intermittent or constant. 

Movable kidney exhibits a tendency to carcinomatous de- 
generation. 

The Urine. — In cases where the movable kidney is neph- 
ritic, albumin and casts will be found in the urine. Otherwise 
in the majority of cases the urine is normal. During Dietl's 
crises, when the ureter is badly strangulated or kinked and its 
lumen temporarily constricted, the urine is scanty, high-col- 
ored, and may contain blood corpuscles, uric acid, and oxalate 
crystals. More or less albumin may also be found at such 
times. 

Simultaneously with the oliguria swelling of the kidney 
from hydronephrosis may take place, followed by an excessive 
flow of clear urine with subsidence of pain and swelling. 

Differential Diagnosis. — The following conditions aie most 
often to be differentiated : 

1. Retained faeces. 



DIFFERENTIAL DIAGNOSIS IN MOVABLE KIDNEY. 61 

2. Dropsical gall-bladder. 

3. Tongue-shaped appendage to the right lobe of the liver 
from constriction or growth. 

4. Pedunculate tumors of uterus or ovary. 

5. Cancer of the stomach or intestine. 

The use of laxatives or the flushing of the colon will serve 
to distinguish the first. 

The second, third, and fourth are distinguished by the in- 
ability to replace them in the region of the kidney. More- 
over, in the case of tumors connected with the liver, the loca- 
tion is more constantly superficial, and the degree of mobility 
more largely controlled by that of the diaphragm. 

The severe digestive disturbances will soon differentiate 
cancer. 

When the disease simulates some affection of the genital 
organs in women the following should serve to distinguish 
movable kidney : 

1. Disorders of digestion, accompanied by pain, not only in 
the right side, but more especially in the left. These pains 
may be characterized as cardialgia or gastrodynia. 

2. General nervousness, the transforming of a naturally 
sweet temper to irritability, with loss of sleep. 

3. Palpitation of the heart, coupled with pain over the 
cardiac end of the stomach. 

4. The usual symptoms directly due to the displacement of 
the kidney, together with the marked emaciation so strong an 
etiologic factor of floating kidney. (Smith.) 

The symptoms may suggest, at the crises, tabes dorsalis 
pregnancy, intestinal obstruction hysteria, uncomplicated 
neurasthenia, and poisoning. 

The nervous symptoms may be mistaken for hysteria or 
hypochondriasis. 

Malignant tumor of the ascending colon has been mistaken 
for movable kidney. (Owen.) 

The pains of indigestion, biliary colic, appendicitis, and 



62 ANOMALIES OF THE KIDNEYS. 

other gastro-intestinal disturbances must not be mistaken for 
that of movable kidney. 

In women of a highly nervous temperament who drink but 
little water the kidneys are sometimes sensitive to pressure. 
(Hartman.) 

Hartman calls attention to the possibility of mistaking 
tumors involving the omentum for movable kidney, as also a 
distended gall-bladder. Patients sometimes complain of the 
pain of movable kidney most during the menstrual period 
and occasionally only during the period, so that it must not be 
mistaken for dysmenorrhcea. 

Tumors of the spleen may be mistaken for movable kidney. 
(See previous chapters.) 

Clinically we find the commonest error is to mistake an en- 
larged gall-bladder for a movable kidney. 

Movable right kidney is to be differentiated from a dis- 
tended gall-bladder : if it is the kidney it will be freely 
movable in all directions, may be carried down toward the 
pelvis and held there during forcible expiration ; may be 
pushed backward and upward toward its normal position, 
where it tends to remain and elude further palpation ; moves 
slightly if at all with respiration, and an area of tympanitic 
percussion (colon) may be found between it and the costal 
margin. 

The gall-bladder on the other hand moves with respiration 
and is not so freely movable as the kidney, though it may be 
moved from side to side or in various radii of a small circle 
having its neck for a centre ; and if pushed backward away 
from the abdominal wall, tends to spring forward to its former 
position when the pressure is removed. Lastly, if the colon 
above which it usually lies has not become looped over its 
neck, there is no tympanitic band between it and the lower 
border of liver dullness. (Butler). 

The floating kidney, when found out of place, may lie as 
low as the brim of the pelvis, or on the opposite side of the 



COMPLICATIONS AND PROGNOSIS. 63 

median line, or directly beneath trie anterior abdominal wall. 
As a rule, it is readily returned to its normal position. 

Associated Maladies. — In women abdominal pelvic condi- 
tions usually co-exist with wandering kidney, as follows : 

i. Displacements of the uterus. 

2. Oophoritis. 

3. Salpingitis. 

4. Inter-menstrual uterine haemorrhage. 

5. Prolonged and profuse menstruation. 

6. Elongation of the blood-vessels of the kidneys, curved 
ureter, hydronephrosis and pyonephrosis, limited twists of the 
ureter and vessels, and adhesions to the transverse colon or 
liver may be found associated with movable kidney in either 
sex. 

Prognosis. — As regards relief from permanent mobility the 
prognosis is favorable ; the relief may be brought about as 
follows : 

1. By accumulation of fat-tissue. 

2. Owing to pregnancy. 

3. The result of mechanical or surgical treatment. 

As regards relief from the symptoms (chlorosis, neuras- 
thenia, hypochondriasis, and mental distress), the prognosis 
depends on the ability of treatment to fix the kidney and that 
of the patient to appreciate intelligently the significance of 
movable kidney. If climacteric is present or approaching it 
is possible that the symptoms may disappear afterward. 

Movable kidney is sometimes nephritic. Use of the 
peculiar ureteral catheter called the segregator will determine 
whether the nephritis is confined to the one kidney or is 
present in both. In the latter case no operation can usually 
be advised and the prognosis is more serious. 

Dangers. — These are as follows : 

1. Hydronephrosis. 

2. Pyonephrosis. 

These are constantly a source of danger ; add also 



64 ANOMALIES OF THE KIDNEYS. 

3. General peritonitis — occasionally. 

4. Destruction of the kidney eventually from degeneration 
(chronic interstitial nephritis) or malignant disease. 

5. Various intercurrent diseases. 

Treatment. — In cases where an operation cannot be per- 
formed, rest should first be tried, no muscular strain what- 
ever being allowed. Occupations requiring an upright posi- 
tion not permitted, and bicycling particularly forbidden. 

The physician should cautiously attempt to replace the 
kidney. 

Place the patient on his back and gently push the kidney 
into place. If the kidney has been forced out of position 
by some strain, enforced rest in the recumbent position should 
be attempted. Next in order, bandaging should be tried. 

The best bandage is made of silk elastic closely fitted to the 
whole abdomen, and prevented from riding up by means of 
straps of soft rubber tubing or other material, one on each 
side, passing from back to front between the legs. Over the 
position of the dislocated kidney is sewed on the inside of the 
bandage a round pocket of soft chamois-skin, left open above 
so that a pad can be pushed into it and changed on occasion. 
(Fitz.) The measurements from which the belt is made 
should be carefully taken, and the pad must be large enough 
to fit the lower quarter of the abdomen so as to make pressure 
backwards and support the kidney. 

In highly nervous patients rest with forced feeding may 
suffice for treatment in case the kidney is but slightly mov- 
able. 

The abdomen should be sponged daily with cold water or 
with brandy. Faradism may be tried, one pole in the vagina, 
the other over the region of the kidney. Mechanical massage 
of the abdominal muscles and organs is sometimes successful. 

Gallant earnestly recommends the use of the corset in 
movable kidney in preference to operation, as follows : 

For routine examination the hand is placed just below the 



TREATMENT OF MOVABLE KIDNEY. 65 

hypochondrium and the kidney displaced by deep inspiration, 
held and palpated, and allowed to escape during expiration. 
In some cases for the bimanual examination the dorsal or the 
upright inclined posture will prove more satisfactory. Some 
of these cases require operation, but 90-95 per cent, can be 
cured symptomatically by wearing a corset. A corset must 
be secured as long in front as can be worn, to elevate and 
support the redundant lower abdominal wall, and form at the 
waist line a shelf on which the kidney may rest. The best 
results, symptomatic and modish, are secured when the corset 
is " made to order," but the so-called " straight-front " corset, 
now on sale in every shop, has given very good results. 

The corset must be not less than two inches smaller than 
formerly worn, laced at the back, from the top and bottom, 
with two flat laces, as an open V, to prevent chafing and 
cutting in thin women, and must be laced very snugly from 
the lowest point to the waist line, loosely from the waist up- 
ward, while the patient is standing. 

Having thrown the corset around the waist, she lies down 
on the bed, draws up the knees, places the head upon a pillow 
to relax the abdomen and permit the viscera to gravitate up- 
ward toward the diaphragm, and while in this position fastens 
the corset. Before hooking the corset she must push the 
kidney into its nest under the edge of the ribs — a very simple 
matter when once learned. The lowest hook of the corset 
must be fastened first, and so on from below upward. As 
each succeeding hook is secured the redundant abdominal wall 
must be drawn within the corset. Any woman a victim of 
nephroptosis must never be permitted to maintain the up- 
right position without having her corset on. A corset fitted 
and applied in this way will maintain a replaceable kidney in 
a position from which it cannot be dislodged downward, and 
will afford relief from all symptoms depending on it. 

Gallant thinks there is a certain appropriateness in curing 
the latest fashionable disease by the latest fashion in corsets ! 
5 



66 ANOMALIES OF THE KIDNEYS. 

There is probably a field for the " corset cure " in some 
cases of a slight degree of movability. 

In the attacks known as Dietl's crises applications of heat 
externally and hypodermics of morphine with atropine may be 
necessary. 

If the severe attacks recur surgical interference may be 
necessary. 

Symptomatic Treatment. — The various phenomena of 
micturition, if they appear, may be treated symptomatically, 
as follows : 

Ignatia : In hysterical cases. Frequent discharge of pale, 
watery urine of low specific gravity aggravated by drinking 
coffee ; lemon-yellow urine with a whitish sediment. Sensa- 
tion of scraping and smarting in the neck of the bladder. 

Sulphur : The patient urinates often with a feeling as if 
there were some obstruction to the flow ; sudden imperative 
desire to urinate or even involuntary micturition. There is 
constant urging to urinate both by day and by night. 

Arsenicum : Retention of urine as if the bladder was pa- 
ralyzed ; scanty urine passing with difficulty ; burning in the 
urethra during micturition ; tenesmus and strangury, great 
desire to urinate but no urine is passed ; or urine copious and 
burning. 

Pulsatilla : Indicated when there is incontinence of urine, 
nocturnal enuresis, involuntary discharge when coughing, or 
discharge of urine in drops when walking or sitting ; spas- 
modic pain in the neck of the bladder after micturition, ex- 
tending to pelvis and thighs ; burning in urethra while uri- 
nating ; hsematuria ; scanty brown-red urine with brick-dust 
sediment. 

Strychnia : Atony of the bladder, retention of urine or in- 
continence from over-distention. 

Gelsemium : This is a useful remedy in cases where there 
is frequent micturition or constant dribbling of urine from 
weakness of the sphincter. Urination is painful and there 



SURGICAL TREATMENT. 67 

may be spasmodic retention from a chill or other causes. 
Spasm of the bladder with alternating dysuria and enuresis- 

Lachesis ; Pressure and pain in the bladder with urging, 
but inability to urinate ; worse after sleep. Turning in bed 
may cause sensation as of a ball rolling in the bladder. There 
may be a sediment of uric acid or urates and severe cutting 
pain during micturition. 

Surgical Treatment. — Morris sums up the question of sur- 
gical treatment as follows : 

i. In movable kidney with enteroptosis no operation should 
be performed until it is clear that the serious symptoms are 
due to the kidney alone, and thorough trial of a well-fitting 
abdominal support and dietetic treatment has been made. 
Should these fail, nephropexy should be tried. 2. In cases 
where both kidneys are movable, they should be fixed one 
after the other at an interval of a week. 3. In hysterical or 
neurasthenic patients, operation should be tried only as a last 
resort. 4. In uncomplicated cases of movable or floating 
kidney, the operation of nephropexy may be confidently 
advised, without previous trial of belts or rest. 5. When 
renal crises are a feature, nephropexy should be strongly 
urged. 6. When a movable kidney gives rise to no incon- 
venience, an operation ought not to be thought of, and a belt 
need not be worn. 

Senn's operation consists in slinging the kidney in a 
hammock of gauze for one week. The two surfaces (that of 
the kidney and of the fat capsule) become granulated and 
coalesce on removal of the gauze. 

According to G. M. Kdebohls, of New York, chronic ap- 
pendicitis dependent upon movable right kidney may occa- 
sionally and under favorable conditions apparently end in 
resolution and remain permanently cured after right nephro- 
pexy. M. L/. Harris's operation consists essentially in con- 
tracting the pouch in which the kidney moves. 



68 



ANOMALIES OF THE KIDNEYS. 



2. ANOMALIES OF FORM. 

These may be either congenital or acquired, usually the 
former. A variety most frequently encountered is the so- 
called "horseshoe" kidney (ren unguliformis), the two organs 
being united by a band of renal tissue, or of condensed fibrous 
tissue, passing over the vertebrae and connecting their inferior 




Fig. 12. — Horseshoe kidney. (From McNutt. 



extremities. (Fig. 12.) The concavity is usually directed 
upward. The two halves are usually complete in themselves, 
each having a distinct pelvis and ureter, and most frequently 
the ureters descend in front of the transverse portion. The 
glands are usually situated lower than normal. 

A horseshoe kidney has occasionally been found in front of 
the great vessels. 

Lobulated Kidney occurs in which the lobulated appearance 
of the foetal kidney is preserved, suggesting an arrest of de- 
velopment in foetal life. 



ANOMALIES OF SIZE AND NUMBER. 69 

Iii some cases the organ may be divided into two or three 
indistinct irregular portions by shallow depressions on its 
surface. 

In a few cases on record one or both kidneys have had two 
distinct pelves, in most instances uniting to form one single 
ureter, although four ureters have been found in one such 
case. 

3. ANOMALIES OF SIZE. 

One kidney may be large and the other proportionately 
small, the larger one being several times the bulk of its fel- 
low. This condition probably arises from deficient develop- 
ment of one of the renal arteries. 

4. ANOMALIES OF NUMBER. 

In rare instances three kidneys have been found in one 
body, the third occupying a position in front of the vertebral 
column or at the side of the normally located glands. In one 
case four kidneys were found, all with their accompanying 
vessels and ureters. 

Solitary kidney is a term applied to fusion of the two kid- 
neys into one mass, which is always a congenital occurrence. 
Every conceivable variety of form and degree of fusion exists, 
from the ordinary horseshoe kidney (the lowest grade of 
fusion) to the completely united variety, resulting in a single 
disk-shaped mass with single or double pelvis. A case of 
S-shaped fusion of the kidneys is on record (ren sigmoideum) 
in which union took place by renal tissue between the lower 
end of the left kidney, in normal position, and the upper end 
of the right, which lay wholly to the left of the vertebral 
column. 

Whenever the only existing kidney has two ureters and a 
double set of blood-vessels, it may be regarded as solitary 

Unsymmetrical kidney is a term applied to the case in 
which there is entire absence of the kidney (presumably from 



70 ANOMALIES OF THE KIDNEYS. 

atrophy), the renal vessels and ureter being likewise wanting. 
It may be congenital or acquired. It occurred once in 318 
sections made by Morris. In man the left kidney is usually 
the one absent ; in woman the anomaly is frequent on both 
sides. It is about twice as frequent in men as in women. In 
women congenital absence of one kidney is often shown by 
unilateral abnormalities in the development of the sexual 
system. 

In cases of unilateral absence of one kidney the other is 
usually but not always hypertrophied, and may even attain 
an enormous size, weighing several pounds. It is likely to be 
misplaced, and to be more or less abnormal in form. 

Absence of both kidneys, together with ureters and bladder, 
has been found in still-born children, especially in acephalous 
monsters. There is one such case on record, of a girl (who 
died at fourteen), in which the renal defect was associated 
with various defects in the genital organs. The urine, or a 
urine-like liquid, continually discharged from the umbilicus? 
which was misplaced. 

CLINICAL NOTES. 

1. Misshapen kidneys are usually misplaced. 

2. When nephrectomy is contemplated the utmost care 
should be taken to examine the generative organs for defect, 
since the latter is often associated with anomalies of the 
kidney. 

3. As long as the single kidney remains healthy there is no 
derangement of the urinary function ; but should it become 
diseased, or its excretory duct obstructed, fatal uraemia rapidly 
supervenes. 

4. Hypertrophy and atrophy of the kidneys will be con- 
sidered under the heading of the various diseases where they 
occur. 

5. The renal artery may not rarely enter the kidney at the 
pelvis by a number of branches either at the side or on the 
convexity of the organ. 



CHAPTER V. 

THE UREMIC PHENOMENA OF RENAL DISEASES. 

Uraemia is the name given to a set of symptoms formerly 
believed to be the direct result of accumulation of urea in the 
blood. We no longer believe that urea is the sole cause of 
the symptoms, various toxic substances being thought to play 
a part in the production of the phenomena, but the name is 
still retained. 

Pathology. — In acute uraemic attacks increased arterial 
tension is regularly noticed, though not always present. The 
association is so frequent that it seems probable that the 
attacks are caused by contraction of the arteries. This belief 
is rendered still more probable by the fact that the symptoms 
usually disappear when the contraction of the arteries is 
stopped. 

In chronic uraemia the arterial tension is not increased, but 
there may be an increased quantity of urea in the blood. 

Etiology. — We find uraemia most commonly due to the 
following causes : 

i. Nephritis, acute or chronic, more commonly in acute 
scarlatinal nephritis and chronic interstitial nephritis. 

2. Calculus impacted in the ureter. 

3. Paralysis of the bladder or over-distention of same from 
stupor. 

4. Obstruction of the orifice of the bladder by calculi, new 
growths or pressure from without. 

5. Strictures, laceration or compression of the urethra. 

6. Phimosis. 

The Diagnosis of Uraemia. — In general it may be said that 
if the urine contains albumin and casts, and the total quantity 



72 



UREMIC PHENOMENA. 



of urea is below 200 grains (13 grams) in twenty-four hours 
the patient is uraemic. For determining the quantity of urea 
the Doremus instrument (Fig. 13), with glass stop-cock and 
side arm, is most convenient. 

Cases occur, however, in which the patient is unquestionably 
uraemic although the quantity of urea is more than 200 
grains in twenty-four hours, and again, so far as the action of 
uraemia on the nervous system is concerned, it is sometimes 
very slight, even when there is much albumin in the urine 
with urea 150 to 200 grains per twenty-four hours. 




Fig. 13. — Doremus's Ureometer with side-arm for the urine. 

In doubtful cases, therefore, it is advisable to test the 
ability of the kidney to do its work on time by means of the 
methylene-blue test. It must be remembered, however, in 
using this test that occasionally this substance is excreted in 
the form of a colorless chromogen. 



DELAYED RENAE EXCRETION. 

Herter's conclusions in regard to delayed renal excretion 
are of interest and as follows : 

Delayed renal excretion may be defined as the postpone- 
ment of the work of the kidney in ridding the blood of its ex- 
cretory solids owing to renal disease. The postponed work 
consists either of the normal work of the kidney in excreting 
urea, salts, etc., or of unusual excretory work imposed on the 



DELAYED RENAL EXCRETION. 73 

kidneys in the course of disease, or for the purpose of testing 
its activity. The substance most often employed in making 
this test is methylene blue. 

Delayed excretion of urea occurs in a variety of pathologic 
states of the kidney, in acute and chronic nephritis, renal 
tuberculosis, amyloid kidney, etc. The delay is expressed in 
the fact that the urea formed in a given time within the body 
and normally excreted in a given period requires a longer 
time for its removal than in health. Thus kidneys which 
have for a considerable period averaged a daily excretion of 30 
gm. of urea may suddenly take two days to do this task, 
while the demand on them continues as before. In such a 
case there would be a well-defined delay in the excretion of 
nitrogen. In acute diseases of the kidney the delay may be 
much greater than in the instance above supposed. Under 
such conditions the work of one day may be prolonged over 3, 
4, 5 or 6 days. Similar delays frequently arise in the course 
of chronic nephritis. During such a delay the urea of the 
blood is increased. If the delay is short, the accumulation of 
urea in the blood is trivial ; but if the delay extends over a long 
period, the increase in nitrogen of the blood may become dis- 
tinctly pathologic. When the percentage of urea rises to 
about 0.3 percent, in the blood, that is, to about ten times 
the normal content, the patient has either developed unmis- 
takable symptoms of uraemia, or is in imminent danger of do- 
ing so. Herter insists on the practical value of knowing the 
percentage of urea in the blood of nephritic subjects. This 
knowledge, which can be readily obtained from an ounce of 
blood, is probably of more definite significance for the out- 
look of a patient with chronic nephritis than any information 
as to delayed excretion. Very often, however, there is hesita- 
tion about bleeding, and then a knowledge of whether there 
is delayed or normally rapid excretion may be very desirable- 

In practice it is not feasible to study the excretion of urea 
with a view to discovering whether it is delayed. This is 



74 UREMIC PHENOMENA. 

owing to technical difficulties which need only be referred to 
here. In place of a study of the nitrogenous excretion, the 
kidney may be interrogated by means of the methylene-blue 
or potassium-iodid test. When methylene-blue is introduced 
into the body of a normal person by injection into a muscle 
(e.g., the vastus internus), it appears in the urine after a few 
minutes (10 to 30). If the dose be moderate, say, one grain 
in ten minims of water, the dye continues to color the urine 
for a period lasting from 15 to 48 hours in different persons. 
In most normal individuals the coloration disappears in the 
course of 36 hours. 

When methylene-blue (in the dose mentioned) is injected 
into the muscle of a patient suffering from nephritis the color 
appears in the urine, usually as promptly as in health, some- 
times after a delay of a few hours. The time required for the 
disappearance of the blue color varies much in different cases 
of nephritis. In many instances of unquestionable renal dis- 
ease associated with albumin and casts in the urine, the dye 
disappears in the course of 36 to 48 hours, as in persons with 
normal kidneys. In other patients there is a distinct delay in 
the disappearance of the methylene-blue from the urine. In- 
stead of quitting the urine in less than three days the colora- 
tion persists 4, 5, 6, or even 7 days and longer. It is this de- 
lay in the disappearance of the dye from the urine that is of 
interest to the practitioner. As already mentioned, there is 
sometimes a delay in the appearance of the blue-green color. 
Some writers have attached importance to this, but we do not 
know enough about the sign to use it in diagnosis. It is cer- 
tainly true that there are cases of chronic nephritis in which 
there is delay in the disappearance of the blue-green color 
without any delay in its appearance. 

Certain conclusions with reference to the methylene-blue 
test seem warranted. 1. A distinct delay in excretion is 
evidence of the inability of the kidney to do its normal ex- 
cretory work on time, owing to structural alterations, or per- 



DELAYED RENAL EXCRETION. 75 

haps temporary disturbances in renal innervation. 2. Such 
a delay, when prolonged (four days or more) and repeated, 
is probably associated with an increase in the urea of the 
blood, and, like such an increase, is to be taken as a sign of 
latent uraemia, even though definite uraemic symptoms be 
absent. 3. Periods of delayed excretion may alternate with 
periods in which there is no delay. 4. The prompt disap- 
pearance of the dye, i. e., within thirty-six hours, may prob- 
ably be taken as an indication that the kidneys are normally 
ridding the blood of urea, salts and other urinary constituents, 
even though the urine contains albumin and casts. 

The use of injections of methylene-blue as a diagnostic 
measure in renal disease is not entirely free from danger in 
some cases in which the kidney is the seat of advanced 
lesions. In acute nephritis with partial suppression, and in 
chronic nephritis with impending uraemia, it may do harm 
by imposing additional work on organs already over-burdened. 
Well-defined, unmistakable ursemic symptoms forbid the use 
of the injections. In a very great majority of cases of chronic 
nephritis there is no objection to their use. When it seems 
undesirable to administer the methylene-blue by injection, it 
can be given by mouth. There appears to be no danger from 
the internal administration of one grain of the dye, except 
possibly in some outspoken acute uraemias. Normally the 
blue is eliminated more rapidly when given by mouth than 
when injected, the usual period being from eighteen to forty 
hours. The rapidity of absorption influences the time at 
which the dye appears in the urine and possibly also affects 
somewhat the time of disappearance. The method is there- 
fore less reliable than the method by injection. Nevertheless 
it is useful, and a delay of three, four or five days in the 
elimination of the dose is to be interpreted in the same way 
as if it had been injected. 

In view of the fact that methylene-blue is sometimes ex- 
creted as a colorless chromogen, the writer's study of this 
chromogen will be of help in doubtful cases. 



76 UREMIC PHENOMENA, 



COLORLESS CHROMOGEN OF METHYLENE-BLUE IN URINE. 

Urine on exposure to air turns greenish. 

Heated with addition of acetic acid, a persistent bright blue- 
green. 

Titrated with uranium nitrate, etc., a bright blue-green 
supernatant liquid. 

Silver nitrate solution (i in 8) gives curdy-white precipitate, 
immediately blackening at the bottom with light blue-green 
supernatant. 

Barium chlorid : white precipitate, faint blue-green super- 
natant. 

Ferric chlorid solution (20 per cent.) : olive green color be- 
low the phosphates. 

The green colors can be obtained when the urine is several 
days old. 

OTHER TESTS FOR URAEMIA. 

In addition to the methylene-blue test the activity of the 
kidneys may be tested by potassium iodid and phloridzin. 
Cryoscopy is also useful in cases when a quantitative analysis 
of the urine is not convenient. 

Potassium iodid can be given by mouth for the purpose of 
testing the activity of the kidneys. In normal adults under 
fifty, a dose of 10 grains is followed by the presence of the 
salt in the urine for a period varying from 24 to 36 hours. A 
delay of more than 40 hours probably indicates some degree 
of renal inadequacy. Further studies of the behavior of 
pathologic kidneys towards this salt are needed. 

Phloridzin Diabetes. — The hypodermic injection of 0.005 
gram of phloridzin is followed by a glycosuria, which, nor- 
mally, begins in half an hour, lasts from two to four hours, 
and in quantity amounts to from 1 to 2 grams. In renal dis- 
eases the appearance of the glycosuria is delayed and the 
amount of sugar less. 



UREMIC CONVULSIONS. 77 

Cryoscopy. — The determination of the freezing point of 
urine by a special apparatus, as Beckmann's, serves to show 
whether the solids in the urine are diminished or not. Normal 
urine freezes from 1.3 to 2.3 C. lower than distilled water. 
In nephritis and other morbid states of the kidney the urine 
freezes with less diminution of temperature, that is, the freez- 
ing point approaches more nearly that of water. 

Clinical Diagnosis. — For clinical purposes the writer as- 
sumes that cases in which loss of muscular strength is noticed, 
together with the presence of casts in the urine, and even but 
a trace of albumin, sought for not only in the night urine but 
in the day, and even if found only in the day, are cases of 
uraemia, especially if the quantity of urea is below 200 grains 
and regardless of whether it is above 200 grains per diem or 
not. 

Symptoms of Acute Uraemia. — The prominent symptoms 
of acute uraemia are the following : Intense frontal headache, 
puffiness of the face, drowsiness or sleeplessness, ringing in 
the ears or light before the eyes, dimness of vision, possibly 
sudden blindness of one or both eyes, dizziness, difficulty of 
breathing, especially on exertion ; nausea, vomiting, in- 
voluntary twitchings, especially of the face and hands; general 
prostration, delirium, hemiplegia, and voiding of urine, which, 
as a rule, is scanty and contai?ts albumin ; convulsions and 
coma may then ensue. In some cases, even after convulsions 
have begun, an abundance of urine may be passed ; but it is 
pale, watery, and contains much albumin. 

In acute uraemia the severest nervous symptoms appear 
suddenly, last a comparatively short time and may terminate 
fatally with convulsions, coma, dyspnoea, feeble heart action, 
fever, and pulmonary oedema. Acute uraemia seldom lasts 
more than a few days. 

Uraemic Convulsions and Coma in Acute Uraemia. — The 
characteristic features of uraemic convulsions are that they are 
equal on both sides of the body. The person is not paralyzed 



78 UREMIC PHENOMENA. 

on one side of the body ; he is not completely unconscious ; 
his pupils tend to dilate ; his appearance is pallid ; his tem- 
perature may be increased from the beginning of the convul- 
sions and range from ioo° to 102 °, but more frequently the 
temperature is subnormal, the pulse is increased, ninety to one 
hundred and twenty beats per minute ; respirations may or 
may not be hastened ; the breathing is of a peculiar, hissing 
character, the noise in breathing being made by the lips ; the 
breath has a peculiar urinous odor. The convulsions are 
likely to recur. They may be preceded by pain and restless- 
ness or come on suddenly. 

Ursemic convulsions are clonic rarely tonic. They vary 
from twitchings to general clonic convulsions with loss of 
consciousness, the so-called urczmic eclampsia. 

Unconsciousness invariably accompanies general convul- 
sions, but coma may develop independently. It is frequently 
preceded by headache. The patient may be dull and apathetic 
before coma. 

Coma may develop without any symptoms of renal disease 
other than the urinary findings. 

The patient may be in a condition of torpor for weeks or 
months at a time, his tongue furred and his breath foul and 
heavy. 

Differential Diagnosis. — Ursemic convulsions or coma must 
be distinguished from apoplexy, epilepsy, hysteria, meningitis, 
typhoid fever, miliary tuberculosis, alcoholic poisoning and 
opium poisoning. 

In apoplexy there is complete paralysis of one side of the 
body following convulsions limited to one side of the body. 
The apoplectic patient almost always turns his head with 
convulsive twitchings to the paralyzed side, and in many 
cases there is very high temperature, 104 to 105 °, and if the 
latter, death will take place in a few hours. Conjugate devia- 
tion of the eyes occurs. 

A suffused face, stertorous breathing, eyes turned toward 



SYMPTOMS OF CHRONIC UREMIA. 79 

the side of hemorrhage, full, slow pulse and hemiplegia should 
suggest apoplexy. (Butler.) 

It is difficult always to distinguish uraemic convulsions from 
epileptic attacks, since patients in the former often injure 
their tongue and simulate very closely an epileptic seizure. 
But if there is history of previous epileptic attacks, and if the 
attack is preceded by a cry, epilepsy is the trouble. More- 
over, uraemic convulsions are attended by greater pallor and 
are more marked than epileptic ones, being equal on both 
sides, while in epilepsy they are more marked on one side. 
Local or Jacksonian epilepsy may occur in uraemia. 

Hysterical spasms resemble uraemic convulsions somewhat, 
but the pupils, face and temperature are normal, and the 
patient is conscious. A choking sensation is often observed 
in hysteria which is absent in uraemia. 

Meningitis with deep coma and slight fever may readily be 
confused with uraemia, but may be distinguished by the mode 
of onset, the rigid neck, the incoherent speech or mild de- 
lirium, the photophobia and pronounced fever. 

Diabetic coma is distinguished by the presence of the red 
reaction in the urine with ferric chloride solution. 

Typhoid fever or miliary tuberculosis is sometimes thought 
to be present when uraemia is the real condition. The Widal 
reaction should be sought for in doubtful cases. 

In alcoholic poisoning the coma is not usually so profound 
as in uraemia and the odor of the breath may serve to differ- 
entiate. 

The comatose stage of uraemia sometimes closely resembles 
opium coma. The contracted pupils, opium breath, slow 
breathing, purplish hue and ghastly expression of the opium 
victim will sometimes distinguish him from the uraemic suf- 
ferer. 

Symptoms of Chronic Uraemia. — Chronic uraemia affects 
essentially the following : 

i. The brain and nervous system. 



80 UREMIC PHENOMENA* 

2. The skin. 

3. The breathing apparatus. 

4. The heart and arteries. 

5. The stomach and bowels. 

6. The kidneys. 

Among symptoms of prime importance is headache. It 
may be anywhere in the head or localized in the forehead, 
vertex, or occiput. Unilateral headache occurs, known as 
urcemic hemicrania. 

Occipital headache is common and extends down into the 
nape of the neck. 

The headache may be accompanied by giddiness. 

In acute uraemia constant, severe frontal headache is 
noticed. 

Neuralgia is of common occurrence ; it is usually supra- 
orbital and occipital. It is quite frequently persistent. 
Vertigo, with sense of weight and pressure in the head, occurs 
in some cases. 

Mental disturbances, melancholia, and even insanity, have 
been known to be due to uraemic poisoning. Whenever 
these come on suddenly the urine should not be forgotten. 
Other cerebral manifestations of uraemia are drowsiness, 
stupor or delirium, convulsions, and coma. 

Insomnia, mental depression and loss of memory occur. 
The most amiable and sanguine dispositions may become mor- 
bidly depressed. The person is peevish, suspicious, impatient, 
or he may feel dull or stupid, with attacks of drowsiness. 

Insanity, due to Bright's disease, is of two forms, according 
to whether the person has insane heredity or tendency or not. 
If he has no such tendency, he suffers merely from a mild, 
quiet mania like dementia. If albumin disappears from the 
urine and he improves in general respects, his mania im- 
proves and he may get entirely well. 

On the other hand, in those predisposed to insanity the kid- 
ney disease acts as an exciting cause ; serious outbursts may 



UREMIC PARALYSIS. 81 

be expected, and there is need of restraint in some institution, 
as suicidal tendencies may develop. 

Delirium may occur, but is a rare symptom. It is usually 
preceded by headache, eye troubles, and mental confusion. 
It is usually of a quiet type, but violent mania with a high 
temperature (107 ) has been known to follow uraemic convul- 
sions. The delirium may be chronic, with hallucinations of 
sight, delusions of persecution, convulsions, and vomiting. 
A case is on record where the patient was furiously delirious 
for several months, and died from collapse. 

The delirium of uraemia may show itself in the following 
manner : The person becomes restless and uneasy, the eyes 
vacant, staring or wild, hallucinations are present, and mem- 
ory is for the time -more or less completely lost. The person 
is, however, more or less rational, and can converse for a 
short time, or answer a few questions, but will repeatedly ask 
questions to which he has just received a reply, and when the 
attack passes off cannot recall anything which has happened. 
Severe headache may accompany these attacks, and the per- 
son is restless at night, tossing about and talking incessantly. 

Peculiar attacks of numbness and tingling may occur in the 
course of chronic uraemia, limited sometimes to the face, but 
possibly including all of one side of the body. In the latter 
case the numbness begins in one foot, usually the left, and ex- 
tends up the side until the left side of the head, including the 
tongue, becomes affected. Motion is not impeded. The at- 
tack lasts from fifteen minutes to half an hour, when it disap- 
pears, leaving no disturbance behind. Numbness and ting- 
ling in the fingers is sometimes noticed. 

UREMIC PARALYSIS. 

Urcemic paralysis may occur either as hemiplegia or mono- 
plegia without cerebral lesions. 

This, in two-thirds of the cases as shown by Baillet, does 
6 



82 UREMIC PHENOMENA. 

not set in all of a sudden ; it is accompanied by convulsions 
or begins with coma. Clinically we find two classes of cases, 
those of chronic and those of subacute nephritis. In chronic 
nephritis after a few insignificant prodromata there is a sudden 
loss of consciousness preceding or accompanying hemiplegia. 
The case may closely resemble one of central cerebral haemor- 
rhage. In subacute nephritis the paralysis may occur in the 
case of children affected with scarlet fever and in pregnant 
women. 

Hemiplegia of uraemic origin is often partial and assumes 
the bronchio-crural type in one-half the cases. In the others 
it is accompanied by a facial paralysis. 

Intensity of Uraemic Paralysis. — This is usually greatest 
at the moment of its appearance or on the following day. In- 
complete paralysis is more frequent in chronic nephritis ; com- 
plete is invariable in subacute. 

The paralyses, as a rule, are flaccid. Contractions, how- 
ever, have been observed by Baillet in severe cases, always 
early in the course of the case. 

Variability. — Uraemic hemiplegia may persist without not- 
able modification until death ends the scene, or it may gradu- 
ually decrease little by little, to disappear almost suddenly 
and to reappear. Its duration varies between a few hours to 
five days. Death generally ends the matter. 

Phenomena Accompanying the Uraemic Paralyses. — Dis- 
turbances of sensibility have been noticed in all uraemic 
states. Though sometimes unaffected, in the majority of 
cases it is diminished or abolished. It should not be for- 
gotten that it is not the grade of the paralysis that regulates 
the sensibility, but the state of the intelligence. 

Reflexes. — The patellar reflex is usually abolished or de- 
creased on the paralyzed side, yet it may be normal or ex- 
aggerated. As to the pupils, they are generally contracted. 

Conjugate deviation was noted by Baillet in a dozen cases 
as associated with the hemiplegia. Ordinarily on the opposite 



CLINICAL FEATURES OF UREMIA. 83 

side to that paralyzed ; it may be on trie other. In three 
cases of this kind it was ascribed to contracture of the muscles 
of the neck of the paralyzed side. 

Thermic Curve. — Most often there is no modification of the 
temperature. In five cases only the elevation noticed ap-' 
peared to be due to uraemic poisoning. In the others it was 
apparently a pulmonary complication to the convulsions, etc. 
On the contrary, a lowering of the temperature has never been 
detected. 

Uraemic Aphasia. — The uraemic aphasia usually is noted 
as a pure motor aphasia, but it is probable that agraphia, to- 
gether with blindness, often complicates motor aphasia and 
word deafness. Uraemic aphasia is generally preceded by 
serious manifestations of urinary poisoning. It is most fre- 
quently -associated with hemiplegia, which is either total or 
partial and generally right-sided. The aphasia may super- 
vene independently of any motor disorder of the limbs or face. 
Three cases of sensorial aphasia without associated motor 
aphasia are reported. 

Prognosis. — From a study of the case it seems that the 
appearance of a uraemic paralysis is of grave prognostic irn- 
portance. Death follows in three-fifths of the cases in a period 
varying from a few hours to a few days. 

Diagnosis. — The diagnosis of uraemic paralysis is of extreme 
difficulty, especially of those cases occurring during the course 
of chronic nephritis. 

Treatment. — Treatment is that of the uraemia in general. 
An abundant venesection appears to be indicated above all 
things, before the administration of diuretics and before com- 
mencing with the milk diet. (Baillet). 

OTHER CLINICAL FEATURES OF UREMIA. 

Aphasia is noticed in some uraemic cases and at times may 
be the sole expression of the state. Riesman offers the fol- 
lowing conclusions regarding it : 



84 UREMIC PHENOMENA. 

It is frequently associated with right-sided motor-paralysis, 
hemiplegic or monoplegic in character. 

It may be the precursor of uraemic convulsions or coma. 

The aphasia is usually of the motor type, but may be sen- 
sory. There may be word- blindness and word- deafness. 

It may be associated with agraphia, even when there is no 
paralysis of the limbs. 

It is comparatively frequent in children, particularly in 
cases of post-scarlatinal nephritis. In adults it may occur in 
any form of Bright's disease. 

It is generally transient, disappearing completely. In time 
it is intermittent, and has a marked tendency to recur. 

When paralysis is present, the two may disappear simul- 
taneously, usually the aphasia first. 

The features of uraemic aphasia are, per se, not character- 
istic of the causal condition. 

The most important diagnostic features are the transitori- 
ness of the aphasia and the presence of other uraemic symp- 
toms and of signs of nephritis. 

In every case of sudden aphasia the possibility of its being 
renal in origin should be considered, and careful studies of 
the urine and of the system at large should be made with this 
thought in mind. {American Medicine, June 21, 1902.) 

Among minor nervous phenomena have been noticed 
cramps, severe tremors resembling shaking palsy, and spasm 
of the flexor of the forearm and posterior muscles of the neck. 

There may be poisoning of the centres of sight and hear- 
ing. Sometimes the person notices that he has dimness of 
vision, perhaps only in one eye, and that when he tries to 
read the letters blur. This is more common in the more 
insidious form of Bright's, without dropsy and with little 
albumin, than in other forms. Again, cases occur in which 
the person is stricken blind without warning, and not until 
this has happened has any one thought it worth while to 
examine the urine. Sudden blindness is occasionally the 



CLINICAL FEATURES OF URAEMIA. 85 

first symptom of uraemia which may be noticed. In other 
cases the failure of vision may be gradual, or the blindness, 
if occurring, be confined to one eye. Fortunately, ursemic 
blindness, though terrifying, is transient in character. It is 
called uraemic amaurosis and usually follows convulsions. It 
lasts only a day or two. 

Among other disturbances of vision, photopsia, or seeing 
flashes of light, may be observed. 

The pupils of the eyes may be small and react sluggishly to 
light. This condition is known as urcemic myosis. 

Blindness of one-half the visual field may occur. The 
patient may see double, objects may be inverted, or there may 
be more or less indistinctness of vision. 

After convulsions amaurosis exists for a day or two. It 
rarely precedes convulsions or appears without them. It 
develops quite rapidly and blindness is soon present. The 
pupils, however, usually react to light, and the retinal image 
is normal when seen by use of the ophthalmoscope. The 
location of the lesion is not known ; it may be due to disturb- 
ance in the occipital cortex. 

The ears are affected in uraemia. Sometimes there is an 
annoying ringing, in other cases there may be failure of hear- 
ing. Deafness may follow convulsions or may accompany 
headache, nausea or other gastric symptoms. 

The mouth may exhibit a peculiar inflammation, uraemic 
stomatitis with furred tongue, foul breath, oedema, hyperaemia 
and swelling of the lips and buccal mucosa. 

The face in uraemia is pallid, the features more or less dis- 
torted, the eyes staring, the breath urinous. The skin in 
some cases may be covered with a whitish deposit of urea 
crystals, the so-called uridrosis. 

The bodily temperature is usually subnormal, but elevation 
of temperature may occur, (i) When there is an inflamma- 
tory process; (2) during convulsions; (3) from unknown 
cause. 



86 URiEMIC PHENOMENA. 

After convulsions the temperature may fall rapidly. Uraemie 
chills sometimes occur. They come on suddenly with other 
uraemie symptoms, and with great increase in temperature 
followed by a rapid fall of the same. 

The skin is affected in various ways, parsesthesia, intense 
itching, burning, erythema, eczema and gangrene have been 
noticed. The patient sometimes has an ammoniacal odor of 
the body. 

Dropsy, if it has been present, may in some cases be mark- 
edly reduced before the onset of uraemie symptoms. 

The subcutaneous tissues are affected as shown by the occur- 
rence of dropsy. 

CEdema may affect the glottis, causing death from suffoca- 
tion in a short time. 

Uraemia may affect the serous membranes, causing pleurisy 
or pericarditis, less commonly peritonitis or meningitis. 

Pneumonia sometimes appears suddenly in the course of 
uraemia. 

Hydrothorax is quite common in uraemie cases. 

Obstinate cough and hoarseness from oedema of the larynx 
may occur. 

The action of the heart and arteries is to cause high arterial 
tension, cardiac hypertrophy, haemorrhages and anaemia. 

The action of urcemia on the blood-vessels is to impair the 
nutrition of their walls, so that they are either unduly perme- 
able or become ruptured. This is shown by epistaxis, the 
vomiting of blood, retinal haemorrhages, purpura and bleed- 
ing of the gums. 

The condition of the pulse in uraemia is an important feature. 
At times an unusual slowness of it is a forerunner of an 
attack of uraemia. In cases of cardiac failure there is a small 
pulse deficient in tension. 

Urcemic dyspnoea may be continuous, paroxysmal, alter- 
nately continuous and paroxysmal, or there may be breathing 
of the Cheyne-Stokes variety. It may persist for weeks or 



DURATION AND PROGNOSIS. 87 

months and yet be followed by recovery. Uraemic cardiac 
asthma occurs in some cases. 

The g astro-intestinal symptoms may appear suddenly. The 
patient may be seized with uncontrollable vomiting; some- 
times the vomiting is preceded by nausea and associated with 
diarrhoea, or there may be diarrhoea without vomiting, some- 
times profuse and associated with intense catarrhal or diph- 
theritic inflammation of the colon. 

In some cases constipation is a feature. I^oss of appetite 
and morning nausea are also noticed. 

The action on the muscular system is shown by loss of 
strength. In the writer's experience this is a classical symp- 
tom of chronic uraemia, occurring when no other symptoms 
appear. 

Finally, death attributed to shock, or septicaemia after 
surgical operations may perhaps be really due to acute 
uraemia. Many surgeons now insist on quantitative analysis 
of the urine before a serious operation is to be performed. 
Careful men will usually not operate when the amount of 
urea per diem is below 12 grammes (185 grains). 

Duration. — In acute cases sudden death may take place ; 
subacute cases may last for eight weeks or more ; chronic 
cases for months or years with periods of marked remission of 
symptoms. 

Causes of Death. -r-Death may be due to (1) Convulsions 
with cerebral or neural paralysis; or, (2) oedema of the glottis 
or lungs ; (3) some serous inflammation ; (4) pneumonia. 

Post-Mortem Appearances. — Intestinal ulcers, the so-called 
uraemic intestinal ulcers, are sometimes found post-mortem. 
They may be due to irritation of the mucous membrane from 
ammonium carbonate. 

Prognosis. — This depends upon the cause. If the case 
is one of acute nephritis the prognosis, though always serious, 
is not hopeless. (See Agute Nephritis.) 

If the case is one of chronic interstitial nephritis the ulti- 



88 . UREMIC PHENOMENA. 

mate prognosis is unfavorable, but remissions may occur of 
months or years. 

If the case is due to a cause surgically remediable, as strict- 
ure or phimosis, the prognosis is more favorable. 

Symptomatic Treatment. — In acute uraemia the remedies 
given symptomatically are Apis, Belladonna, Conium, Glonoin, 
Gelsemium, Stramonium, Veratrum viride, Agaricus, Ana- 
cardium, Hydrocyanic acid, Iyactuca and Opium. In chronic 
uraemia Arsenicum, Aurum, Cuprum, Hydrocyanic acid, 
Nicotin, Phosphorus and Terebinth. 

In addition to the above Ammonium carb., Carbolic acid, 
Cannabis Indica, Cantharides, Cicuta, Arsenite of Copper and 
Helleborus have been advised by various physicians. 

The indications for the use of these remedies will be found 
under the heading of the treatment of the various disorders in 
which uraemia occurs. 

Palliative Treatment. — If the patient is in a stupor with a 
distended bladder the urine is to be drawn with a carefully 
sterilized catheter. If there is phimosis, this is to be at- 
tended to. 

In other cases eliminative treatment by diuresis, diaphore- 
sis and catharsis is to be pursued. (See Acute and Chronic 
Nephritis.) 

Bichhorst gives a formula for removing the foul odor of the 
breath as follows : Benzoic acid, four and a half grains ; cam- 
phor, three-quarters of a grain ; sugar, seven and a half grains. 
Make into ten powders and give one every two hours. 

For the unpleasant itching of the skin tepid baths and 
inunctions of carbolated ointment may be tried. 

In general, diaphoresis and catharsis is the treatment ; if 
these are insufficient or the case is grave, venesection with 
counter-injection into the veins of normal salt solution should 
be tried, especially when there are convulsions or coma. 

The subcutaneous injection of sterilized serum is said to be 
a successful measure. 



CHAPTER VI. 

DISTURBANCES OF THE CIRCULATION OF THE KIDNEYS. 

The amount of blood in the kidney is subject to marked 
variations. The circulation is under the influence of the 
vaso-motor system, but the nerves accompanying the renal 
vessels are small. They are derived from the renal plexus and 
particularly fiom the lesser splanchnic nerves. The blood- 
vessels of the kidney are plentiful, and their distribution such 
that the medullary blood supply is to a considerable extent 
independent of the cortical, hence disturbances in the one do 
not necessarily affect the other. 

The disturbances which will be considered in this chapter 
are, I. Thrombosis. II. Embolism. III. Anaemia. IV. Hy- 
peraemia, active and passive. 

RENAL THROMBOSIS. 

Thrombosis of the renal vein is a cause of passive hyperae- 
mia, which see. 

Thrombosis of the renal vein in infants may result from 
traumatism during- delivery or from septic infection. In 
anaemic or cachectic infants marantic thrombosis, so-called, 
may occur. 

Thrombosis of the renal artery is rare, and more frequently 
affects the left than the right on account of its longer course 
across the aorta. The causes are inflammatory and degenera- 
tive changes in the arterial walls and surgical ligation. In 
aneurism of the abdominal aorta the blood clot may some- 
times extend into the renal artery. The kidney is swollen 
and cedematous, and often presents numerous haemorrhages, 
which occasionally are extensive. 



90 DISTURBANCES OF CIRCULATION. 

RENAL EMBOLUS. 

Synonym. — Infarction of the kidneys. 

Definition. — Renal embolism consists of an impacted, non- 
irritating thrombus, formed somewhere in the circulatory 
system and carried to the kidney, where it blocks a terminal 
renal vessel. 

Fat emboli in connection with those in the lungs, and in 
fractures, pyaemia and surgical operations occur. Pysemic 
emboli are also known. 

Etiology. — Endocarditis, especially left ; valvular diseases 
of the heart ; parietal thrombi in aorta. Emboli come from 
the cardiac valves, in form of detached fibrin or atheromatous 
material, or from arterial thrombi, aneurisms, or atheromatous 
patches. Infectious results occur when emboli contain 
bacteria. 

Pathologic Anatomy. — Most commonly emboli reach the 
kidney through the left renal artery for anatomical reasons, 
but they rarely lodge in the artery; in case of lodgment 
necrosis of the whole kidney, except small subcapsular areas, 
takes place; as a rule, the emboli are swept into smaller 
branches and we find an ischemic wedge-shaped area of 
necrosis in the region supplied by the obstructed vessels, of 
opaque gray- white or red-gray color surrounded by a dark red 
zone. The dead portion is eventually absorbed and replaced 
by a scar adherent to the renal capsule, often containing 
blood pigment. If pyogenic bacteria in embolus, then ab- 
scess. 

Microscopically : Area of necrosis of tubular epithelia. 
Fat-drops eventually appear. Interstitial inflammation near 
infaret (embolic contraction) in certain cases. 

In case there are several emboli in the renal vessels then 
we may find a multinodular irregular surface and an atrophic 
appearance of the organ. 

Clinical Features. — Previous history of endocarditis. Sud- 



RENAL ANEURISM. 



91 



den pain in the back, with vomiting and chills, especially if 
heart is weak. Sense of precordial oppression or clogging, 
and frequently dyspnoea. Slight temperature. Some little 
collapse. 

The Urine.— Abrupt change in the urine ; decreased quan- 
tity, increased color, specific gravity and acidity. Sudden 
appearance of albumin, blood and casts. In from two to five 
days gradual improvement, until urine is normal again, in 
three or four weeks at most. 

Prognosis. — -Favorable. 

Treatment. — Absolute rest in bed at uniform temperature. 
Warm clothing. Careful nursing. Milk diet. In case of 
feeble persons eggs and limited amount of small farinaceous 
or cereal foods. 

If the pain is severe an ice-bag may be applied to the loin 
or morphine given in small doses subcutaneously. 



RENAL ANEURISM. 

The symptoms are tumor, loss of appetite, dyspeptic symp- 
toms and wasting, with occasional attacks of pain. The 
tumor is smooth, elastic, with expansile pulsation, and may 
be about the size of a foetal head, beneath left costal arch, ex- 
tending from ribs to a hand's breadth below navel, apparently 
fixed in renal region. Diagnosis is difficult. If such a 
tumor develops rapidly after an injury or severe exertion in a 
patient with arterio-sclerosis, but without marked cachexia, it 
should suggest renal aneurism. 

In some cases the patient dies suddenly from internal 
haemorrhage before the condition is suspected. 

The treatment, if the condition is discovered, is solely 
operative, removal of the organ by nephrectomy as described 
by W. W. Keen, of Philadelphia. 

ANEMIA OF THE KIDNEYS. 

Etiology. — The principal causes are as follows: General 



• • 

• Il • nl otili i i n 

obsti in i '• > " '" lh< '■ n (1 ' '• • ml»'»li in ..i i hroi 

pres HI li ""I ' liroinbo ilfl oi 

renal artei ) fro I It Intliii i; >jm uti >dii co 

tlOtJ M,.n -li In. ml ill. ,|| 'hi- . I 01 K 

of the \ i . in li i. m . iftci i athetei 

:: ton ol i In hi in m . tract, and also 
cpilcp -\ . lead - "li* and puerp 
eclampsi 

Pathology.— According to the duration oi the anaemia and 
the sudden- ss iset the ch in the kidneys are 

found tc cases short duration the kidney is some- 

what pal smallei md harder than normal. In chronic 
anaemia generation of the epithelium is eomrnou. 

Comple: - follows total obstruction of the renal artery 

or its partial obstruction leads to various degenera- 

tive changes : milder degree. 

Clinical Features. — Inasmuch as the quantity of urine de- 
ne in the kidney the principal 
ti r or anuria. In hysteria 
lay be present foi d lys will. 
b i the .uun i.i that somel ii 

iiind oi i M hetei in in cause d< 
n ilso in pin i pern I eclanip 

ill in m\ i i s< •. o| .m.niii.i 

in i In <;l..iu. i nli In a i 

• mi i i. .iiii.i i . . i ol urobili 

it i< ii it I ml i low i <it io ol i 

I. .1 li in . i nil |>llo .p||< 'i 1- 

nl lorn liom nl mil 
ml in ilu i, Jinn nl h il 

. i mi i 
1 1 1 . | i ||| I , . I , , . | . 1 1 1 1 i 
III I In In 

|,,, | | Ini ||| II iimI 



ANEMIA AND HYPEREMIA. 



93 



pressed, although containing a trace of albumin and various 
casts, is of high color but not high specific gravity with de- 
ficiency of urea and phosphoric acid will differentiate from 
hyperemia. 

Anaemia of the kidneys must be differentiated from nephritis, 
especially from chronic interstitial nephritis (chronic diffuse 
nephritis with induration). The differentiation is to be made 
largely by a thorough clinical examination of the patient with 
a study of the history and causes. If the urine is of high 
color but low specific gravity as in pernicious anaemia, this 
should suggest at once an examination of the blood. From 
other forms of chronic nephritis the small amount of albumin 
and the absence of fatty or waxy casts will aid in the differ- 
entiation. 

Treatment. — The treatment of anaemia of the kidneys 
resolves itself into that of the varied conditions to which the 
anaemia is due. 



ACTIVE HYPEREMIA. 

Synonyms. — Acute hyperaemia, acute or active congestion. 

Definition. — Abnormal influx of arterial blood into the kid- 
neys. 

Etiology. — i. Acute hyperaemia may occur, temporarily, 
after exposure to cold or excessive ingestion of fluids ; it may 
result from nervous polyuria or occur in diabetes mellitus or 
insipidus. 

2. It is frequently found after extirpation of one of the kid- 
neys or following surgical operations on the urinary tract. 

3. It may result from long-continued lithaemia or oxaluria. 

4. It is caused sometimes by the blood poisoning of certain 
diseases, as malaria, the eruptive fevers and inflammatory dis- 
eases, by poisoning with cantharides, turpentine, ether, chloro- 
form. 

5. Protracted, active hyperaemia is likely to result in acute 



94 DISTUBBANCES OF CIRCULATION. 

nephritis, which see. This condition always precedes acute 
inflammations of the kidneys. 

6. It sometimes depends on hypertrophy of the heart, and 
occurs in exophthalmic goitre. 

7. Temporary congestion of the kidney, according to Bec- 
quet, takes places at every menstrual period. 

8. In general in conditions of heightened arterial pressure, 
excessive or unusual exertion, as in athletic games or mental 
excitement. 

Pathology. — Active hypersemia depends, as a rule, on pa- 
ralysis of the vaso-constrictor nerves of the renal arteries ; 
perhaps also upon stimulation of the vaso-dilators. 

Pathologic Anatomy. — Kidneys. — Macroscopically, we find 
them normal or slightly enlarged. Moist, firm. 

Capsule. — Normal. Strips easily. 

Renal Surface. — Smooth, dark red in color. 

Cut Surface. — Dark. Cortex a little darker than pyramids. 

Renal Substance. — Soft, vessels engorged with blood. 

Malpighian Tufts. — Congested, appear as dark red points in 
cortex. 

Epithelia. — Deeper in color than normal. 

Blood-vessels. — Microscopically we find them distended 
with blood. 

Location of Congestion. — Principally on arterial side and in 
capillary loops of glomerulus. In other words, the morbid 
process lies mainly in the renal arteries and the arteries of the 
Malpighian tufts. 

Clinical Features. — Aching in the loins as along course of 
ureters or radiating to hips. More or less prostration. Tender- 
ness over renal region on deep pressure. Nausea, vomiting, 
perhaps headache. If due to fevers, symptoms of pyrexia. 

If due to poisons, as cantharides, turpentine, then frequency 
of micturition, together with, perhaps, pain, urgency, or vesi- 
cal tenesmus. 

If due to over-exertion the only signs may be the changes 



THE URINE IN ACTIVE HYPEREMIA. 95 

in the urine. Acute congestion of the kidneys may be a very 
alarming and often a very sudden malady. The fibrous cap- 
sule of the kidney being unyielding, there is not only blood 
stasis but pressure and arrest of function, partial or complete, 
which is soon followed by very grave symptoms. Dropsy 
may or may not be present, but nearly always there is head- 
ache, dyspnoea, scanty urine, deep-seated pain in the back 
over the kidneys, and certain nervous symptoms which may 
develop into delirium, coma and convulsions. 

Convulsions may occur even if albumin is absent from the 
urine, due, it is claimed by Rachford, to xanthin and para- 
xanthin increased in the blood and found also in the urine. 
In severe cases after nephrectomy the patient may pass into a 
typhoid condition with delirium. After injury collapse may 
supervene with suppression. 

The Urine. — Blood the feature, the quantity of it ranging 
from a few scattering corpuscles, in mild cases, to very bloody 
urine in severe. 

Albumin. — Small or none. Rarely above 10 per cent. bulk. 

Casts. — Few, small, hyaline or none. 

Epithelium. — Free renal, often ; not always found. 

Quantity of Urine per Twenty-four Hours. — First, slight 
polyuria; later, volume deficie7it. Color and specific gravity 
increased. Complete suppression may occur. 

Solids, Grains per Ounce. — First, diminished ; later, in- 
creased. 

CLINICAL NOTES ON THE URINE. 

i. In cantharides poisoning, clots of fibrin may appear in 
the urine. 

2. Congestion with suppression may occur without either 
blood or albumin in the urine ; as congestion subsides the first 
urine voided will be heavily loaded with urates ; albumin and 
casts absent. 

3. A sediment of urates is common in this disorder. 



96 DISTURBANCES OF CIRCULATION. 

4. In some cases the quantity of urine is much below 
normal, but albumin is absent. In such Rachford has found 
xanthin and paraxanthin in the urine. 

5. After foot-ball games the urine of players may contain 
albumin and casts : blood, epithelial and granular. 

Differential Diagnosis. — From acute nephritis by absence 
of dropsy or anasarca. From passive congestion by absence 
of cardiac lesions, and absence of passive congestion of the 
liver. 

From anaemia of the kidneys by the history and causes, 
and usual presence of blood in the urine in greater or less 
amount, and by the usual relative increase of solid matters 
(grains per fiuidounce) even if the total amount is small. 

Prognosis. — Almost always favorable but depends on cause ; 
if this is functional, disorder is transitory. In malarial poison- 
ing, or that by irritating diuretics, suppression, uraemia, and 
death may occur. If the patient was previously nephritic 
prognosis unfavorable. The hyperaemia which occurs after 
surgical operations may prove fatal if continuing more than 
two days. 

A single attack is not in itself dangerous, but repeated at- 
tacks are conducive to nephritis. Where serious complications 
do not occur the prognosis is good. The dangers are sup- 
pression of urine, convulsions and coma. 

Treatment. — In urgent cases when the urine is very scanty 
or suppressed the patient is to be put to bed and kept on thin 
rice gruel for food. He should be given large quantities of hot 
water to drink ; hot foot baths should be given him and hot 
applications to the region of the kidneys should be made. Rectal 
injections of warm normal salt solution should be frequently 
made. Lithia tablets (five grains) should be dissolved in the 
hot water taken by the patient four to six times daily. 

In cases in which the congestion is not of many hours 
standing dry cupping and sweating with hot drinks as lemonade 
or flaxseed tea will often restore the function of the kidneys. 



TREATMENT OF ACTIVE HYPEREMIA. 97 

In plethoric cases when all measures fail to relieve the 
convulsions venesection may be tried or veratrum viride hypo- 
dermically. In some cases the treatment is that of the fever 
or inflammatory disease on which the congestion depends ; 
'or the removal of the poison or irritant, if the disorder is 
caused by such. 

Symptomatic Treatment. — Terebinthina : Useful in acute 
congestion of the kidneys when there is scanty, dark colored 
urine containing blood and albumin. To be used in small 
doses not to exceed one drop. Stimulating diuretics (in 
material doses) like Juniper, Turpentine and Squill must be 
avoided in acute hypersemia. 

Lithia: The soluble compounds of Lithium are serviceable 
in the milder cases where there is severe pain in the back, 
but as yet the urine is not suppressed and contains but little 
or no albumin. There is scanty high-colored urine with an 
abundant sediment of urates and a few blood corpuscles, 
microscopically. The writer has speedily relieved a number 
of mild cases of this sort occurring in the course of la grippe 
by hot applications to the kidneys and lithium citrate in- 
ternally in five-grain doses four times daily, in water. 

Eucalyptus : This remedy in doses not to exceed one drop 
of the oil every two or three hours may help restore the func- 
tion of the kidneys when given after cupping. 

Glonoin: In cases of chronic nephritis subject to acute 
hypersemic attacks this remedy may be used in doses of ^io of 
a grain every two hours until the patient passes urine more 
freely. 

Chloride of Gold and Sodium : Given under about the same 
conditions as Glonoin, according, however, to symptoms pres- 
ent, especially the mental ones, and the voiding of more urine 
at night than during the day. May be given as low as -fa of 
a grain, four times daily. 

Aconite: Useful in cases where the congestion is due to 
over-exertion or exposure to cold. 

7 



98 DISTURBANCES OF CIRCULATION. 

Arnica: In cases due to over-exertion and injury. 

Dulcamara : In cases due to exposure to cold. 

Mercurius cor.: When there are gastric and hepatic symp- 
toms, pain in the back, frequent micturition. 

Veratrum viride: In cases due to surgical operations, 
trauma or shock. 

Camphor : In cases due to poisoning by Cantharides. 

Other remedies sometimes indicated are Belladonna, Can- 
tharides and Sandal-wood. 

The writer uses Terebinth and Glonoin most, occasionally 
Aconite. 

Surgical Treatment. — For the relief of tension in a severe 
case of acute renal hyperaemia Adams split the kidney in two, 
making the incision along the convex border of the organ. 
The operation resulted in recovery. The symptoms suggested 
stone in the kidney. 

ANURIA AFTER THE USE OF ANESTHETICS. 

Whether the anuria following the use of anesthetics is due 
to acute hyperaemia or not, it is convenient to consider it here. 

Etiology. — Saturation with ether causing a depression of 
the circulatory system and interference with the flow of blood 
through the kidneys ; exposure of the patient to cold during 
operative procedure ; operations on the lower urinary tract., 
(See Urinary Fever.) 

Treatment. — The rectal injection of normal salt solution is 
an efficient measure, and should be used freely if there is 
arterio-sclerosis. Nitroglycerine hypodermically if there are 
evidences of cardiac or circulatory depression. Strychnine is 
a valuable stimulant, and also moderate doses of Digitalis. 

In cases where there is a tendency to spasm of the renal 
arteries because of the presence of arterio-sclerosis the admin- 
istration of nitroglycerine is often followed by a free secretion 
of urine. {Therapeutic Gazette.) 

In some cases the use of normal salt solution per rectum 



PASSIVE HYPEREMIA. 99 

fails to produce diuresis. Hot applicatious to the region of 
the kidneys, pilocarpine and alkaline waters may be tried, or 
nitroglycerine as above. In one case the writer knows of 
symptomless anuria followed an operation for vaginal hyster- 
ectomy and lasted for forty-eight hours, until the ligature was 
removed from the right uterine artery. 

PASSIVE HYPEREMIA. 

Synonyms. — Chronic congestion, venous stasis, passive 
congestion, cyanotic induration of the kidneys, engorged kid- 
ney, chronic hypersemia, hypostatic kidney. 

Definition. — Engorgement of the renal veins, due to ob- 
struction of the venous current preventing normal escape of 
blood from the kidneys. Since the renal veins have no valves, 
whenever cardiac or pulmonary obstruction to the circulation 
arises the venous blood is dammed back through the inferior 
vena cava and renal veins into the kidneys. 

Etiology. — The causes may be either general or local. 
Most commonly we find it in (a) mitral regurgitation and 
stenosis, (b) myocardial disease, (c) pericarditis, (d) em- 
physema. It also occurs in obstruction or fatty degeneration 
and dilatation of the right heart, aortic aneurisms, excessive 
pleuritic adhesions; in chronic interstitial pneumonia, in 
chronic bronchitis and fibrous phthisis. In death from suf- 
focation an acute form has been noticed. 

IvOcal causes which may bring about passive congestions 
are (a) thrombosis of the inferior vena cava above the en- 
trance of the renal veins, (b) thrombosis or compression of the 
renal veins which may be due to pressure of tumors, fluids 
or cicatricial bands, or to extension of inflammatory disease 
from the kidney itself or to extension of thrombosis from the 
vena cava. A form of spontaneous thrombosis occurs in 
cachectic infants suffering from wasting diseases. The preg- 
nant uterus by pressure may also be a cause. 



LofC 



100 DISTURBANCES OF CIRCULATION. 

Clinically we find passive congestion of the kidneys most 
common in diseases of the mitral valve, hence the term, 
"cardiac kidney." The writer has occasionally found it also 
in cases of long-standing pleuritic effusion. * 

It may occur also in cases of cirrhosis of the liver. In chronic 
diseases of the heart it is a sign of weakness of the myo- 
cardium sufficient to allow the venous blood to accumulate 
abnormally in the renal veins. 

Pathologic Anatomy. — The changes in the kidneys vary 
according as the congestion is recent or of long continuance. 
In the latter case the change is characteristically termed 
cyanotic induration. 

Kidneys. — Usually enlarged. Thicker than normal. 

Capsules. — About normal. Non-adherent. 

Renal Surface. — Smooth, congested, purple. 

Cut Surface. — Appears succulent, .but is quite firm ; turns 
deep crimson on exposure to air. 

Renal Substance. — Very hard. India rubber feel. Color 
dark. 

Cortex. — Slightly thickened, dark. Stellar veins of Ver- 
heyen very prominent. 

Medulla. — Deeply congested, darker than cortex. 

Malpighian Bodies. — Enlarged, distinctly visible. 

Interlobular Veins. — Prominent, distended. 

Vence Rectce. — Especially congested and distended. 

Pyramids. — Have striated appearance, due to congestion of 
vense rectae. Bases dark, of purplish hue. 

Summary. — The marked changes are in the medulla, the 
bases of the pyramids showing marked congestion, the deeply 
congested vessels shining prominently between the bundles 
of uriniferous tubes, causing the tissue to look striated. In 
cases due to thrombosis the kidneys are ©edematous as well as 
hypersemic. 

Microscopically we find : 

Veins. — Much congested, especially the large ones and the 
interlobular plexuses. 



CLINICAL FEATURES OF PASSIVE HYPEREMIA. 101 

Malpighian Bodies. — Very prominent, Bowman's capsule 
filled, sometimes distended. Possible rupture of tuft capil- 
laries. 

Epithelium. — But slightly altered, swollen, sometimes gran- 
ular, rarely fatty. May contain reddish pigment granules. 

II. Older Cases. — Microscopically we find the following : 

Kidneys. — Slightly smaller than normal ; slight degree of 
granular atrophy. Hard, dark red kidneys. 

Capsule. — Adherent to nodular surface in places. 

Renal Surface. — Shows small, pale, wedge-shaped patches 
of dense tissue, inward along course of interlobular veins. 

Renal Substance. — Feels almost fibroid. 

Malpighian Bodies. — More or less atrophied within the 
patches. 

The Veins. — Show as dark, vertical striae. 

Cortex. — Paler than the pyramids. 

Microscopically in the older cases we find a thickening of 
the capillaries, of the veins, and sometimes even of the arteries. 
The glomeruli are only occasionally atrophic. The tubular 
epithelium is more or less degenerated, and in part detached 
from the basement membrane. Areas of round cell infiltra- 
tion may be present. 

This characteristic change is known as cyanotic induration. 

In extreme cases the condition may pass into a state of con- 
traction known as hypostatic contracted kidney. 

Clinical Features. — i. Those of the primary disorder. 
Usually we find a patient with a valvular murmur, more or 
less displacement of the apex beat, greatly engorged liver, 
and hydrothorax, especially on the right side. There is 
dyspnoea, which is most marked about midnight, a weak, 
rapid arhythmic pulse, and sometimes a hacking cough. 
There is oedema of the lower extremities and ascites, seldom 
much oedema about the face. The patient is weak and has 
periods of great mental depression and anxiety. In long 
standing cases more or less cyanosis may be observed. 



102 DISTURBANCES OF CIRCULATION. 

One of the earliest symptoms is dyspnoea on exertion. 

The Urine. — The feature is scanty, cloudy, reddish, acid 
urine of high specific gravity and with sediment of urates. 

Albumin. — Small, seldom above second mark on Ksbach 
tube. 

Casts. — Few, small hyaline, with occasionally a few blood 
corpuscles in them. A few pale granular casts. 

Sediment. — Contains mucus and urates, a few blood cor- 
puscles, uric acid crystals. 

Solids. — Uric acid relatively increased. 

Stress is to be laid on the fact that in this disease high 
colored urine is associated with high specific gravity, 1,020 or 
upwards. As high a specific gravity as 1,035 has been noticed 
by the writer. Patients may pass not over ten or twelve 
fluidounces (300 to 360 c.c.) of urine for weeks or months at 
a time unless relief from treatment is to be had. 

Albumin varies in percentage ; usually by Purdy's centrif- 
ugal method the percentage is from five or less to fifteen, 
seldom as high as the latter unless there is an acute exacerba- 
tion or a nephritic complication. The writer has never seen 
fatty or waxy casts in this disorder before nephritic complica- 
tion sets in. A noticeable feature is the slowness with which 
the urine filters after hydrochloric acid has been added to it 
and it has been allowed to stand twenty-four hours. 

The changes in the urine are attributable in the first place 
to the diminished afnux of arterial blood to the Malpighian 
tufts; and second, to pressure of the dilated veins upon the 
uriniferous tubules. 

Differential Diagnosis. — The color, specific gravity, quan- 
tity of albumin and kind of casts are significant in this dis- 
order, so far as the nrine is concerned, while in the patient 
presence of valvular disease of the heart and its phenomena 
are of importance, viz.: The murmur, displacement of apex 
beat, engorged liver, hydro thorax, ascites, etc. In cases, 
however, where the hyperemia depends upon pressure, as 



PROGNOSIS IN PASSIVE HYPEREMIA. 103 

from pleuritic effusion or tumors, much depends upon the 
history. Effort must be made to discover whether the patient 
has a history of pleurisy. 

Patients may say they have had la grippe, while in reality 
pleurisy was the disorder, and an effusion is still present. 
Aspiration may reveal fluid, especially on the right side, which 
is above 1,015 in specific gravity. In one obscure case of 
chronic hypergemia removal of nine pints of such fluid resulted 
in a restoration of the urinary condition to nearly normal. 

Passive hypersemia is to be differentiated from, (a) anaemia 
of the kidneys ; (b) active hyperaemia, and (c) chronic diffuse 
nephritis, especially from that with induration (chronic inter- 
stitial). 

The following table will help to differentiate from the last : 



PASSIVE HYPEREMIA. 



PRIMARY CHRONIC INTERSTITIAL 
NEPHRITIS. 



Albumin, small. Albumin, small. 

Casts, few hyaline. Casts, few hyaline. 

Volume of urine, decreased. Volume of urine, increased. 

Color, dark. Color, pale. 

High specific gravity and grains per Eow specific gravity and poor quality 

ounce of solids. of urine. Sp. gr. iu acute attacks 

not so high. 

Abundant sediment. Scanty deposit. 



Dropsy early. Dropsy late. 

No high tension. Signs of high tension. 

No visual disorders or chronic Visual disorders and chronic uraemia. 

uraemia. 

Cyanosis. No cyanosis. 

Nocturnal micturition not common. Nocturnal urination the rule. 

Prognosis. — That of the primary disease. Essentially un- 
favorable, but depends on the degree of compensation for the 
mitral defect by hypertrophy of right ventricle. When fatty 
degeneration or dilatation takes place, death within a few 
months. Effective compensation may relieve patient for sev- 
eral years. 



104 DISTURBANCES OF CIRCULATION. 

Tendency to acnte intercurrent nephritic attacks is an un- 
favorable sign. 

The urine usually decreases when oedema of the feet and 
legs appears. 

Acute exacerbations due to excesses, indigestion or sudden 
exposure to cold occur. The urine then is more albuminous, 
with possibly blood and blood casts. 

Intense dropsy and almost complete anuria are not neces- 
sarily fatal in this disease. 

Temporary improvement often occurs,, but relapses are 
common. 

Complication of chronic nephritis is possible if the disease 
last long enough. Granular casts then appear and remain. 
Patient may then die in a few days from uraemia. 

The writer has seen several patients live for a year or more 
by virtue of vigorous treatment, when dropsy and dyspnoea 
were severe and the patient confined to his bed for the time. 

The general tendency is gradually downward, with occa- 
sional periods of comparative health and comfort. The apex 
beat is found after a time to be widely displaced and wavy ; 
as the heart dilates the patient grows feebler, and finally takes 
to his bed. Such a course is more likely in this disease than 
sudden death during an apparent amelioration, though the 
latter is possible. 

Cause of Death. — Death takes place from cardiac paralysis 
or from suffocation due to excessive hydrothorax or pericardial 
effusion. 

Treatment. — In early stages the treatment is that of the 
primary disorder, usually valvular disease, and will not be 
minutely considered here. 

In general, however, rest alternating with bodily activity, 
resistant exercises and carbonated baths with remedies directed 
rather toward keeping up the patient's general health than 
stimulating the heart itself are valuable. 

Illoway's rules for the dietary in chronic heart troubles are 
the following : 



TREATMENT OF THE DROPSY. 105 

• 

(a) All foods that have bulk must be excluded. 

(b) All flatulent foods must be excluded. 

(c) Only foods that are readily digestible should be taken. 

(d) All foods must be well cooked. 

(e) All meals should be small. 

(/) There should be sufficient interval between meals. 

The diet list for organic heart disease includes fresh eggs 
and milk, lamb broth, cocoa and crackers, rice and well- 
cooked farinaceous foods. All food should be well cooked, 
but never fried. Eating moderately and slowly is also ad- 
vised. ( The American Journal of the Medical Sciences, 
March, 7902.) 

Treatment of the Dropsy. — The physician will usually be 
called on to allay the patient's alarm by reducing the dropsy. 
The writer has succeeded in accomplishing this in a few 
weeks' time by means of the following treatment : 

The patient is put on exclusive milk diet for a period of 
several weeks. The milk is taken four times daily at regular 
intervals, as, for example, at 8 A. M., 12 noon, 4 and 8 P. M., 
in quantity each time from two to six ounces the first week, 
and from ten to sixteen the second week. If the milk diet is 
given for three weeks, then during the third week the quan- 
tity may be further increased to twenty ounces at a time four 
times daily. Simultaneously with the adoption of the milk 
diet the following drugs are administered : Epsom salt in 
large doses, namely, a heaping tablespoonful dissolved in 
water, three or four times daily, the fourth dose being omitted 
as soon as the copious, watery stools relieve dyspnoea suffi- 
ciently to allow the patient to sleep at night. Inasmuch as 
the excretion of urine in these cases is scanty there is need to 
increase it on account of the danger of uraemic symptoms, 
notably drowsiness and delirium, which may follow the sud- 
den reduction of the dropsy by the salts. For increasing the 
urine I give fresh infusion of digitalis in doses of from two to 
four teaspoonfuls three times daily, alternated with potassium 



106 DISTURBANCES OF CIRCULATION. 

citrate in doses of from fifteen to thirty grains in plenty of 
water. If there is as yet no marked failure of compensation 
the dropsy may be removed by these means in less than three 
weeks, and the patient, who may at first have measured from 
forty-eight to more than fifty inches about the umbilicus, is 
reduced in size until he measures less than forty. During 
the third week the Epsom salt is decreased in amount given 
to two doses, or even one dose daily ; the citrate of potassium 
may usually be discontinued altogether in the third week, and 
the doses of digitalis reduced in amount and in frequency. The 
patient now begins to take solid food in moderation, avoiding 
hearty eating and omitting meat altogether from his dietary, 
but at the same time taking nourishing food. He is allowed 
all the fresh air he can get without exertion. As soon as 
possible it is well to discontinue the use of digitalis, and to 
give China or Phosphoric acid frequently and in material 
doses. The patient is likely to have relapses from time to 
time, when it will be necessary to resume the digitalis infu- 
sion and give the Epsom salt more frequently for a few days. 
In one case it has been necessary also to resume the exclusive 
milk diet every now and then. Finally, if evidences of fail- 
ure of compensation begin to be shown as by increasing dila- 
tation and tricuspid murmur, the remedies are arsenicum and 
strychnine, or the arsenate of strychnine. In general, it may 
be said that if the amount of albumin in the urine is small, 
usually less than ten per cent, by bulk, if casts are few and 
not fatty or waxy, and if in the patient arterio-sclerosis or ex- 
treme cardiac dilatation is not marked, we can by the treat" 
ment described above keep down the dropsical condition for 
months or even years. In one case thus treated after two 
severe attacks of dropsy a year apart, the patient, an elderly 
man, recovered entirely so far as dropsy is concerned, and at 
the end of four years is still free from it. 

If the dropsy is obstinate and resist the action of salts, as oc- 
casionally happens, tapping may be resorted to and usually 



TREATMENT OF THE DROPSY. 



107 



need not be repeated if the treatment described above be 
undertaken after the tapping. Occasionally it may happen 
that the patient cannot tolerate Epsom salt, in which case 
elaterium in doses of T V to | grain once or twice a day may be 
preferable. 

If hydrothorax is marked, aspiration may be resorted to. 
In one case which I saw this operation was followed by dis- 
appearance of general anasarca and ascites for several months. 
But it is likely to return and the effect of repeated aspirations 
seems to be bad. 

If, for any reason, the patient is unable to undergo the 
severe purgation above described, reliance must then be 
placed upon diuretics. There are two great diuretic remedies, 
digitalis, which acts on the circulation, and theobromine, 
which acts on the kidneys themselves. The efficiency of 
digitalis may be increased by administering it in the form of 
a mixture with strophanthus, the active ingredients of squill, 
and a glucoside known as oxysaponin, the whole called hydra- 
gogin ; the irritant qualities of theobromine may be lessened 
by administration of it in the form of a mixture known as 
agitrin consisting of five parts theobromine acetate and two 
of sodium acetate. The activity of agurin is said, moreover > 
to be much increased when administered in combination with 
digitalis and it is most efficient in dropsies due to valvular 
diseases of the heart. It acts upon the kidneys and not upon 
the heart, hence the more intact the kidney the greater 
its efficiency. It is best given dry in doses of fifteen grains to 
adults four times daily. 

An excellent combination is the following : 

Powdered digitalis leaves, one grain and one-half ; agurin, 
fifteen grains. Make into ten capsules and give one capsule 
every two hours. Diuretin may be used in case it is not 
possible to procure agurin. 

The writer has used agurin with marked success as a 
diuretic in one case in which it was advisable to discontinue 
digitalis and Epsom salt for a considerable period of time. 



108 DISTURBANCES OF CIRCULATION. 

It is assumed in the above that contraindications to the use 
of digitalis are not present. These are as follows, according 
to Edwards : 

(i) Balanced compensation. 

(2) If rest in bed, active purgation, etc., have not been 
previously attempted. 

(3) Adequate hypertrophy. 

(4) Where danger exists in the direction of vessel tupture, 
as in very marked atheroma, aneurism, etc., recalling the fact 
that brain hemorrhage may follow the incautious use of 
digitalis, strychnia and other drugs which result in over- 
action of the heart and vaso-motor spasm. 

(5) Marked fatty degeneration of the heart. This does not 
apply to fatty degeneration in toto, but merely to extreme 
grades of the lesion, since we know that fatty degeneration is 
often merely an evidence of malnutrition, possibly of stasis, 
and may be helped by digitalis. 

(6) When the vessels are contracted strongly, we obviate 
angiospasm by combining the drug with strophanthus, or 
nitroglycerine, which, especially in aged hearts, is recom- 
mended by Balfour. To use his expression, nitroglycerine 
" unlocks " the peripheral vessels. 

When digitalis is given for a long period, it is Edwards' 
personal preference to combine it with the iodides. 

Regarding the cumulative action of the drug, which is 
denied by many, but nevertheless must be admitted, the drug 
should be given with intermissions, although it may be 
kept up in small doses for months, or even years. Great 
care must be exercised in ambulatory, dispensary, or office 
patients. Care must be exercised when the drug has been 
used in dropsy, since sudden absorption of the fluid may re- 
sult in toxic symptoms, precisely as uraemia may follow dis- 
appearance of oedema. Again, toxic symptoms may inter- 
vene when the drug has been given during fever, upon whose 
cessation or crisis toxic symptoms frequently develop. 



TREATMENT OF CHRONIC HYPEREMIA. 109 

The indications for the use of digitalis are the following : 
Dilatation, functional dissociation (hence valuable when there 
is over-activity of the left ventricle) and rapid heart action. 

Colon flushing and injection of warm normal salt solution 
may aid the diuretics in acting upon the kidneys. 

For cardiac dyspnoea and pain heroin may be used instead 
of morphine. It can be given continuously for months in 
doses of one-tenth of a grain three times daily. 

Strophanthus in the dilutions '(not in the tincture) is recom- 
mended by Geo. Royal. He says : "Give Strophanthus when 
the muscular fibers of the heart have been made brittle by 
rheumatism deposits or by the prolonged and excessive use of 
alcohol, tea or tobacco ; when this condition of the heart 
muscle has produced a weakness which has interfered with the 
venous circulation, and has thereby caused passive congestion 
and an inflammation of the kidneys, which in turn has caused 
a decrease of the secretion of urine with the resulting dropsi- 
cal swelling of the extremities, edema of the lungs, impaired 
vision, etc." 

Royal claims that in chronic renal hyperemia strophanthus 
will decrease the dropsy, and increase the urine when indicated 
as above. He uses it in the second or third decimal. 

Guar ana is especially indicated in cases of mitral disease 
and general dropsy. Its diuretic effect is prompt and said to 
be efficient in dropsy dependent upon cardiac weakness. It is 
less dangerous than digitalis. It may be given in form of 
elixir in large doses, a dessertspoonful every two or three 
hours. 

Caffeine is also useful in cases when the heart is weak. 
The dose is from two to five grains four times daily. Either 
the pure alkaloid or the citrate may be used. 

The weak heart appearing at the close of this condition may 
sometimes be strengthened by employment of the faradic 
brush for two or three minutes daily over the region of the 
heart, and by application of hot cloths. The most useful 



110 DISTURBANCES OF CIRCULATION. 

remedies are strychnine, -^ grain, combined with atropine, jho 
grain, every six hours, in cases where blood-tension is low 
and supra-renal extract, three to five grains, every six hours 
when the heart is acting against greatly diminished peripheral 
resistance. 

Camphor internally and camphorated oil externally, ether, 
valerian-root, and ethereal tincture of valerian may also be 
employed. 

It may be remarked here that patients with passive conges- 
tion do not bear sweating well and that pilocarpine is not 
usually to be thought of. 

Multiple incisions or puncture, if needed, are safer than at- 
tempts at diaphoresis. 

Symptomatic Treatment. — Phosphorus : A prominent in- 
dication is a weak, empty feeling in the whole abdomen. 
Disease of the right heart with consequent stasis. Fatty de- 
generation of the myocardium ; dyspnoea ; tightness across 
the chest ; great weakness with inability to exertion, es- 
pecially indicated in tall, slender patients. 

Arnica : General dropsy with a bruised feeling. In cases 
following over-exertion and in fatty heart. 

Digitalis : Sensation as if the heart would stop beating if 
the patient moves ; hydropericardium ; suffocating spells, 
sinking feeling in the epigastric region, sensation as if about 
to faint ; useful in cases when the congestion is due to en- 
feeblement of the left ventricle. 

Convallaria : In hypertrophied and dilated heart with rapid 
irregular action ; general dropsy and lameness in the back, 
worse on lying down. 

Aconite : Oppression about the heart, burning flashes along 
the back ; palpitation with feeling as if boiling water were 
poured on the chest ; anxiety, difficulty of breathing, flying 
heat in the face, sensation of something rushing into the head, 
faintness with tingling. 

Useful in cases of over-action of the heart, which, how- 



TREATMENT OF CHRONIC HYPEREMIA. 



Ill 



ever, is uncommon in this disorder. In the writer's experience 
Aconite is particularly useful in the lower potencies for the 
sensation of something rushing into the head. 

Belladonna and Veratrum Viride may also be employed, the 
former where there is a throbbing of the carotid and temporal 
arteries, the latter in over-action of the heart with a full, hard, 
bounding pulse. But these conditions are rarely encountered 
in this lesion of the kidneys. 

Other remedies which may be indicated are Apis, Cactus, 
Camphor, Chloralum, Colchicum, Crataegus, Kalmia, Nux 
vomica, Spigelia and Apocynum. 

The writer used Crataegus and Apocynum with marked 
relief to the patient in the case of an elderly woman who had 
been taking Digitalis without effect. Crataegus was given in 
ten-drop doses of the tincture, alternately with Apocynum 
can. in seven-drop doses of the tincture alternately every three 
hours. The patient rallied from an apparently moribund 
condition and lived several months after the family had gath- 
ered together, supposing her to be on her death-bed. Con- 
firmatory of the value of these two drugs is the experience of 
J. C. Andrews, of Edge wood, California, who gave Lloyd's 
specific Crataegus in five-drop doses in water every three 
hours, alternated with Apocynum can. 31J, in water siv, a tea- 
spoonful every three hours. Andrews's patient, though ap- 
parently on the point of death, rallied and lived a week. 



CHAPTER VII. 

INFLAMMATIONS OF THE KIDNEY. 

The kidneys are influenced by the blood, and in turn them- 
selves influence the blood. If the blood brings to the kidneys 
substances which, during elimination, damage them, they in 
turn, through faulty elimination, modify the state of the 
'blood, which thus altered irritates the kidneys still more. 

Richard Bright, 1 789-1858, was the first to bring the 
clinical symptoms and urinary changes into relation with the 
morbid anatomy of the kidneys. The term " Bright's dis- 
ease " has been given to inflammations of the kidneys unat- 
tended by suppuration. Confusion, however, is unavoidable 
if the term Bright's disease is used to denote various forms of 
nonsuppurative renal lesions which were unknown to Dr. 
Bright. In speaking of inflammations of the kidney the 
term nephritis is in general preferable. Diseases of the kid- 
neys are, as Riesman says, perhaps the most obscure field in 
pathology, despite the labors of Dickinson, Stewart, Virchow, 
Bartels, Weigert, Rosenstein, Senator, von Kahlden, Coun- 
cilman and Delaneld, and no unanimity exists regarding a 
method of classifying them. Formerly, clinicians distin- 
guished two types of nephritis, parenchymatous and inter- 
stitial, but a sharp line between these inflammations cannot 
be drawn. 

Delaneld classifies nephritis as follows : Acute exudative, 
acute diffuse, chronic productive, or diffuse with exudation, 
chronic productive or diffuse without exudation, suppurative, 
and tubercular. This classification has been adopted by 
several authors of text-books on the practice of medicine. 
From a pathological point of view it is thorough and careful, 



INFLAMMATIONS OF THE KIDNEY. 



113 



but the clinician, as a rule, prefers a classification which, by its 
nomenclature, gives him a clearer idea of the structures of the 
kidney affected and of the post-mortem appearances as re- 
gards gross pathology. With view, therefore, to the needs of 
the general practitioner, we shall adopt in this book the classi- 
fication of Riesman. 

■•■,- 

According to Riesman {American Text-Book of Pathology.) 
the nonsuppurative lesions are acute nephritis, chronic neph- 
ritis, and amyloid kidney. 

Acute nephritis is either parenchymatous, i. e., one which 
consists principally of degeneration of the parenchyma, or 
diffuse, i. e., one in which the two chief structures of the kid- 
ney, namely, the parenchyma and the supporting tissue, are 
involved. 

The latter form may be chiefly glomerular (acute 
glomerulonephritis), or interstitial (acute interstitial nephritis)- 

Chronic nephritis is either non-indurative or indurative. 
The term non-indurative is applied to that form of chronic 
nephritis in which there is no induration or hardening from 
scar-tissue or contraction. Post-mortem shows a large, soft 
kidney (large white, or large yellow kidney), except in harnior- 
rhagic cases, where the consistence is greater than normal. 

The term indurative, on the other hand, is applied to those 
forms of chronic nephritis in which there is induration or 
hardening of the kidney. There are three varieties : (i) Sec- 
ondary chronic interstitial nephritis, an advanced stage of 
non-indurative nephritis ; (2) primary chronic interstitial 
nephritis, formerly called granular or contracted kidney, 
which develops insidiously without evidences of preceding 
inflammation, and in which, post-mortem, a small, hard, gran- 
ular kidney is found, and (3) chronic arterio-sclerotic nephritis 
which in some rare cases may be due to primary arterio- 
sclerosis in the kidney without noteworthy changes in the 
interstitial tissue, and in which we find, post-mortem, a hard 
" beefy " kidney, normal in size or smaller. 



114 ACUTE INFLAMMATIONS OF THE KIDNEY. 

The terms non-indurative and indurative are gradually find- 
ing their way into the reports of clinicians and pathologists, 
and in order to have an intelligent understanding of the writ- 
ings of modern observers the classification above given must 
be carefully considered. 

A classification based upon the part of the kidney affected 
is both theoretically and practically possible, as we can readily 
distinguish post-mortem changes in the structures. 

ACUTE NEPHRITIS. 

Clinically we distinguish acute nephritis from chronic as 
one which arises with comparative rapidity from various in- 
jurious influences, and which terminates after a few days 01 a 
few weeks either in recovery or in death, or occasionally after 
a rapid onset passes into the chronic form. 

ACUTE PARENCHYMATOUS NEPHRITIS. 

The writer is a believer in the possibility of clinical demon- 
stration of this form of renal lesion, which is really a degen- 
eration, as the vascular phenomena characteristic of inflam- 
mations are absent. Riesman says : It often passes into diffuse 
nephritis from which it cannot be separated clinically, and 
only with difficulty at the post-mortem. The writer has, 
however, seen cases which were degenerative from the first 
day, and in which death took place before any of the features, 
clinical and urinary, of diffuse nephritis occurred. 

Pathology. — The feature is degeneration of the parenchyma 
of the kidneys, cloudy swelling, dropsical change, hyaline 
and fatty degeneration, and necrosis. 

Etiology. — Acute infectious diseases, anaemia, jaundice, 
pregnancy and poisons are the causes. 

Pathologic Anatomy. — The Kidneys. — Somewhat enlarged 
and paler than normal. Consistence diminished. Rather 
friable. 



ACUTE PARENCHYMATOUS NEPHRITIS. 115 

The Capsule. — Tense, thin ; strips easily. 

Sectio7i. — Pale surface, less translucent than normal, 
" cooked " appearance. 

The Cortex. — Sometimes marked with reddish striae or 
dots ; width increased ; bulges a little. 

The Pyramids. — Darker than cortex. 

Microscopically : Exudation into Bowman's capsule, and 
degenerative changes in the tubular epithelium, especially in 
the convoluted tubules. 

Clinical Features. — In nearly every acute infectious disease 
there is probably more or less parenchymatous degeneration 
of the kidney. In mild cases there are no symptoms. In 
more severe cases slight albuminuria (febrile albuminuria). 
In severe cases diminution in the quantity of urine, increase 
in the color and specific gravity, presence of more or less al- 
bumin but of a relatively large amount of casts which are in 
very large proportion granular. The writer has seen several 
cases, not, however, of pregnancy, but dependent on jaundice 
or septicaemia as a cause, where, with only a small percentage 
of albumin, hundreds, or even thousands, of granular casts 
could be found on every slide examined. 

In the cases thus seen by the writer, oedema and other 
features of nephritis have been absent and the urine has been 
entirely free from blood corpuscles or blood coloring matter. 

In all the cases referred to the urine was known to be nor- 
mal before the illness causing the renal change, and yet in a 
few days casts were found in great numbers and were en- 
tirely large dark casts usually significant of advanced degen- 
erative changes. But no evidence of inflammatory changes 
was to be had in the cases before these casts appeared ; blood 
and hyaline casts or a large quantity of albumin did not ap- 
pear first nor any clinical features in the patient significant of 
acute diffuse nephritis. 

Prognosis. — That of the disease on which the lesion de- 
pends. If the degeneration passes into a diffuse nephritis the 



116 INFLAMMATIONS OF THE KIDNEY. 

prognosis becomes that of this disorder. In the writer's ex- 
perience, no matter how many or how large casts are found 
in the urine in the course of jaundice they invariably disap- 
pear if the patient recovers from the jaundice, and the urine 
then becomes normal. 

If the primary cause of the disease cannot be ascertained 
the prognosis may be grave. 

Treatment. — The treatment is that of the disorder on which 
the disease depends. In a general way, however, limitation 
of the diet to non-nitrogenous food or milk foods, free inges- 
tion of fluids together with remedies, such as the lithium 
compounds, corn-silk, digitalis if necessary, and possibly 
jaborandi have been the ones most used by the writer, with 
special reference to the urinary condition. 

ACUTE DIFFUSE NEPHRITIS. 

Definition. — An acute inflammation of the kidney charac- 
terized by simultaneous changes both in the parenchyma and 
stroma. There are two sub-classes: Acute glomerulo-neph- 
ritis and acute interstitial nephritis. 

ACUTE GLOMERUEO-NEPHRITIS. 

Etiology. — Acute glomerulo-nephritis is of (a) infectious, 
(o) septic, or (c) of external toxic origin, sometimes (d) due to 
pregnancy, and sometimes (e) follows exposure to cold or is 
due to unknown causes. 

I. Infectious Origin. — Secondary to all the acute infectious 
diseases, principally scarlet fever ; also to diphtheria, infec- 
tious sore throat, cholera, the plague, typhoid, small-pox, 
erysipelas, cerebro-spinal meningitis, typhus, dysentery, epi- 
demic influenza and even whooping-cough, mumps, measles 
and chicken-pox ; to chronic infectious diseases, as tuberculo- 
sis, malaria, syphilis, rarely to dysentery. 

Due to passage of soluble specific virus through the kidneys, 
i. e., products eliminated by pathogenic microbes. 



ACUTE GLOMERULONEPHRITIS. 117 

The nephritis of acute articular rheumatism and pneumonia 
is classified under this heading. 

It is probable that a latent and insidious chronic nephritis 
may cause acute nephritis. 

Clinically, we find acute nephritis most common in scarlet 
fever, small-pox, cholera, diphtheria, erysipelas and croupous 
pneumonia among acute diseases, and in tuberculosis among 
chronic diseases. 

II. Septic Origin. — Morbid processes combined with sepsis, 
suppuration and inflammation ; surgical affections, pyaemia, 
septicaemia, puerperal fever, diphtheritic and valvular endo- 
carditis ; certain skin diseases, eczema, acute pemphigus ; 
inflammatory conditions of the lower urinary passages. 

In the writer's experience, however, the nephritis, if of short 
duration in these cases, is likely to be acute parenchymatous 
rather than diffuse. 

Adhesive pericarditis with pus in the pericardial sac is 
known to have caused a fatal acute nephritis in a child three 
and one -half years old. 

Hoist claims that frequently a general infection, clinically 
speaking, assumes the mask of an acute haemorrhagic ne- 
phritis. He insists upon the close relations between endo- 
carditis and acute nephritis, and concludes that : 

i. Acute hsemorrhagic nephritis is, more frequently than is 
now generally admitted in practice, the expression of an in- 
fection of the blood, or in other words, of a latent pyaemia, or 
of a septo-pyaemia. 

2. The transitory haemorrhagic exacerbations which are so 
often noted in the course of a chronic nephritis possibly in 
many cases may be due to a temporary infection of the blood 
(septo-pyaemia). Perhaps there may be a recrudescence in 
valvular affections of a haemorrhagic nephritis similarly to the 
recurrent lighting up of inflammation in the endocardium. 
Thus one may speak of a recurrent haemorrhagic nephritis as 
one speaks of a recurrent endocarditis. 



\ 



118 INFLAMMATIONS OF THE KIDNEY. 

III. External Toxic Origin. — Due to poisoning by canthar- 
ides, turpentine, copaiba, cubebs, mineral acids, oxalic acid, 
carbolic acid, nitre, potassium chlorate, potassium chromate, 
potassium iodide, phosphorus, arsenic, corrosive sublimate, 
oil of mustard, scilla, salicylic acid, quinine, and coal-tar prod- 
ucts, ether, chloroform, sulphuric acid, glycerine, boracic 
acid, opium, sharp condiments. External applications of car- 
bolic acid, iodoform, frictions with tar, storax, Peru balsam, 
petroleum, napthol, chrysarobin, pyrogallic acid, and various 
ointments for scabies and psoriasis. Ptomain poisoning, as in 
violent gastritis and intestinal catarrh, is also classified under 
this heading. Also that of severe burns. 

IV. Other Conditions. — Acute nephritis is also known to 
follow sudden chilling, as when a person breaks through ice ; 
exposure to cold and wet, as in battling with snow or wad- 
ing ; and it also occurs in the course of pregnancy. 

There is reason to think that even in these cases the ne- 
phritis is really the result of infection, though this has not 
been proved. It is known to occur as an independent in- 
fectious disease with staphylococcus pyogenes albus in the 
urine. 

A large proportion of all cases of acute nephritis can be re- 
ferred to a few common varieties of pathogenic organisms. 
The pneumococcus, the pyogenic streptococci and staphy- 
lococci, the bacilli of diphtheria and of typhoid fever, and the 
Plasmodia of malaria, separately and in various combinations, 
are responsible directly or through their secretions for many 
cases of acute nephritis. Add to these the renal lesions caused 
by infectious diseases of unknown nature, as scarlet fever, 
measles, syphilis, and influenza, and the number of acute 
cases unaccounted for is not large. (Herter.) 

It must not be forgotten that in mild epidemics of scarlet 
fever there are always a number of cases with no eruption 
whatever, or an eruption so slight and transient as easily to 
escape observation, yet cases of acute nephritis may follow 
these. 



ACUTE GLOMERULO-NEPHRITIS. 



119 



Bearing upon the etiology of acute nephritis Blum has 
shown that of 140 cases 70 per cent, could be traced to acute 
infectious diseases, while 2.85 per cent, only were referred to 
cold and 6.42 per cent, to unknown cause. The various dis- 
eases investigated showed the following : 

Typhoid fever 873 cases, acute nephritis, 31 

Scarlet fever 97 " " " 4 

Measles 45 " " " 1 

Erysipelas ... 162 " " " 7 

Variola 481 " " " 1 

Diphtheria 93 " " " 4 

Tonsillitis 74 " " " 4 

Ulcerative endocarditis . . . . 10 " " " 1 

Acute rheumatism 360 " " " 4 

Acute pneumonia . . .... 140 " " " 26 

Pyaemia 12 " " " 8 

Blum does not, however, distinguish between acute paren- 
chymatous and diffuse nephritis. 

Occurrence. — Males are more subject to the disease than 
females, especially those who are exposed to cold and wet. 
Alcoholics frequently are attacked by it, possibly, however, 
from exposure while intoxicated. 

It occurs as a complication in gonorrhoea, cystitis, pyelitis, 
and paranephritis. 

Goulkewitch has found evidences of nephritis in 22 of 220 
autopsies of infants from 2 to 9 months old. 

Pathologic Anatomy of Acute Glomerulo-nephritis. — The 
Kidneys. — Usually enlarged. Weigh from 400 to 500 grams. 
Color, grayish-white, grayish-red, or dark red ; often mottled 
with red and white points. Consistency diminished. Organ 
friable. 

The Capsule. — Stretched taut, strips easily, adherent in a 
few places. 

Stellate Veins. — Well-marked. 

Section. — Shows cortex to bulge and become convex ; cor- 



120 INFLAMMATIONS OF THE KIDNEY. 

tex wider than normal, and of a dnll grayish-pink or grayish- 
yellow color ; striations indistinct ; sometimes marked with 
reddish dots and lines. 

Malpighian Bodies. — Show as prominent red points. 

Pyramids. — At juncture with cortex, hypersemic and red. 
Elsewhere usually dark red but sometimes pale. 

In advanced cases the section of surface is mottled by yel- 
lowish or grayish-yellow areas ; haemorrhagic foci not disap- 
pearing on pressure may also be present. (Riesman.) 

Histologic Changes. — These are three in number: (i) 
Glomerular, (2) tubular, (3) interstitial. 

The glomerular changes vary greatly ; in some cases of 
acute diffuse nephritis they are slight or even absent ; but in 
the majority they are the most striking, hence the term 
glomerulo-nephritis. The changes may be either (^prolifera- 
tion of the capillary endothelial cells or (b) Proliferative and 
degenei r ative changes in the epithelmm of the capsule of Bow- 
man. Both the inter-capillary and the desquamative glomer- 
ulitis are accompanied by an increased permeability of the 
capillary walls, hence the excretion of an albuminous urine. 
In addition there is also (c) Adhesive glomerulitis character- 
ized by an exudation of fibrin, which passes in the form of 
threads from the inner to the outer layer of the capsule, 
analogous to an adhesive pericarditis, etc. 

The tubular changes are principally degenerative, with a 
few proliferative, most marked in the convoluted portion, and 
in character as in acute parenchymatous nephritis. The 
lumen of the tubules contains granular detritus, tube-casts, 
detached cells, hyaline masses and red blood corpuscles. In 
some cases desquamation is marked, hence the term desquama- 
tive nephritis. 

The changes in the interstitial tissue are as follows: (1) 
Exudation of fluid ; (2) emigration of leucocytes ; (3) diapede- 
sis of red blood cells often amounting to distinct haemor- 
rhages ; (4) proliferation of the fixed connective tissue cells ; 



ACUTE GLOMERULONEPHRITIS. 



121 



(5) appearance of the so-called plasma cells of Unna ; (6) 
alteration in the blood vessels. 

When the haemorrhagic process is intense, the term acute 
hemorrhagic nephritis is used. 

In the acute nephritis of scarlatina and diphtheria the 
changes in the interstitial tissue are most marked. 

Onset of the Disease. — In cases due to exposure the onset 
is usually rather sudden, in those due to fevers less so. The 
patient gradually becomes pale, and puffiness in the face or 
oedema of the ankles is first noticed. In cases due to mineral 
poisoning a typhoid condition sets in after subsidence of the 
acute toxic symptoms. 

Clinical Features of Acute Glomerulo Nephritis.— The prin- 
cipal features are oedema, ancemia, and diminished secretion of 
urine, the latter containing blood, albumin and casts. In 
young children convulsions may be the first symptom noticed. 
Chills, fever, pain, nausea and vomiting may also occur as 
well as a large number of symptoms, which are more con- 
veniently grouped as follows : 

The Eyes. — These appear swollen, due to oedema of the 
lids, which is an early and common feature. In the eye 
itself haemorrhagic retinitis occurs in some cases. 

The Head and Face. — Intense headache, especially before 
ursemic attacks. 

The face is pale and cedematous. Cutaneous oedema of 
the face may be the earliest or only symptom, the eyelids par- 
ticularly being swollen and a remarkable narrowing of 
the palpebral fissure noticed. 

The soft palate, larynx and glottis may become cedematous 
as also the conjunctiva. There may be subconjunctival 
haemorrhage. 

The Skin. — There may be marked oedema under the entire 
skin to such an extent as to cause rupture of it. The skin is 
dry, anaemic, and of translucent appearance. 

Erysipelas or gangrene may develop as a result of inflam- 
mation of the skin from oedema. 



122 INFLAMMATIONS OF THE KIDNEY. 

Respiratory Tract. — There is dyspnoea from hydrothorax, 
hydropericardium and ascites. 

A form of pneumonia sometimes develops. 

Pulmonary oedema is not rare and oedema of the glottis 
may occur. 

The Heart and Arteries. — The blood pressure is increased, 
the aortic second sound accentuated often to a ringing char- 
acter ; sometimes there is hypertrophy of the left ventricle. 
Acute dilatation of the heart may rapidly develop with fatal 
issue. 

Kpistaxis and subconjunctival haemorrhages are noticed, 
also haemfituria. 

The Temperature of the Body. — This may be unchanged, 
but, as a rule, it is elevated at times as high as 102 ° or above. 
In young children temperatures from 101 to 103 ° may be 
noticed for a few days. Chilliness and rigors are noticed in a 
few cases. 

The Muscles and Nerves. — Pains in the muscles and joints 
are common. Severe backache may precede an attack of 
uraemia. Severe bilateral sciatic neuritis has been noticed. 

The Pulse. — Is often hard and tense; at first, slow, but later, 
accelerated. 

The Gastro-Intestinal Tract. — There is loss of appetite, but 
increased thirst. Nausea and vomiting are common, some- 
times diarrhoea. 

The Urinary Tract. — There is usually frequency of 
micturition and there may be difficulty in voiding urine, with 
vesical tenesmus and pain. 

The Blood. — There is anaemia ; diminution in red corpus- 
cles and per cent, of haemoglobin is noticed. It appears early 
and is very generally present. 

Urcemia. — Early in severe cases; the symptoms are severe 
headache and backache, vomiting and convulsions. Sleep is 
disturbed and appetite lost. Transient aphasia may occur. 
Uraemia occurs in only a limited number of cases, some- 



DROPSY IN ACUTE NEPHRITIS. 



123 



times in the beginning, more often, later. It is most com- 
mon in scarlet fever cases. 

Dropsy. — The dropsy may follow the acute initial symp- 
toms in a day or two and rapidly increase, or may gradually 
appear during convalescence from the acute infectious disease. 
Puffiness of the eyelids is usually first noticed, followed by in- 
volvement of lower extremities, genitals, and dependent parts 
of the trunk. 

The dropsy is most common in (a) post-scarlatinal cases, (b) 
those due to malaria, (c) pregnancy, and (d) exposure to cold 
and unknown causes, (e) in alcoholic cases, (f) in cases follow- 
ing cutaneous diseases, as scabies or pustulous eczema. A 
violent and rapidly fatal nephritis may be accompanied with 
but little dropsy. 

The dropsy that distinguishes renal disease in the absence 
of cardiac lesions competent to account for the symptoms is 
probably due to alterations in the smallest blood vessels and 
in a very large proportion of cases is associated with well-de- 
fined glomerular lesions in the kidney, these in turn probably 
dependent on the action of toxic substances or pathogenic or- 
ganisms which reach the kidney in the blood stream. That 
is, certain poisons in the blood are capable of producing both 
glomerular lesions in the kidneys and changes in the vessels 
of the skin which permit the transudation of serous fluid. 
The dropsy may be in some cases due also to weakness of the 
heart, in which case it is congestive. 

In nephritis cedema begins in the skin, notably in that of 
the face. It is sometimes slightly inflammatory, as shown by 
the redness and tenderness of the skin. In some cases there 
may be dropsical transudations into serous cavities (hydro- 
thorax, ascites, hydropericardium) without cedema of the 
skin. CEdema of the mucous membranes also occurs : of the 
conjunctiva, soft palate, glottis, etc., and resembles a mild 
local inflammation. Lastly, there occurs cedema of the in- 
ternal organs, as, for example, pulmonary and cerebral, which 
is sometimes inflammatory. 



124 INFLAMMATIONS OF THE KIDNEY. 

The dropsy is a thin blood-serum, composed of from 97 to 
98 per cent, water, one and one-half per cent, salts, a little al- 
bumin and a little urea. 

Secondary Inflammations. — During nephritis secondary in- 
flammations may appear in almost all the internal organs, and 
often quite suddenly, especially in the retina. 

The Urine. — Is diminished in amount and contains albumin, 
blood and casts in a majority of cases. The color is light red, 
like meat water, or red-brown or brown-black from methemo- 
globin. Clots are absent. The sediment in addition to blood 
corpuscles contains cylindrical structures of adherent haemo- 
globin. The specific gravity is high at first, 1.020 to 1.025, 
but later falls to 1.0 15 or 1. 010. Hematuria is marked in 
the cases known as nephro-typhoid. 

Atypical Cases. — 1. In some cases the entire clinical picture 
is that of acute meningitis ; fever, prostration, restlessness, 
sleeplessness, delirium, headache, stupor, typhoid state, with 
little or no dropsy ; absence of albumin, casts and blood from 
the urine, but presence of pus. 

2. In children, fever, gastro-intestinal symptoms, drowsi- 
ness, mild convulsive seizures or simply anaemia may be the 
only symptoms of an acute nephritis. 

3. There may be no symptoms to attract attention except 
abdominal pain, speedily followed by coma. 

4. Cases are described by Delafield in which there is high 
fever, typhoid, cerebral and circulatory symptoms with anaemia 
and dropsy mostly in the legs. Blood is absent from the 
urine and casts few. Albumin in the urine is abundant. 
There is dyspnoea, vomiting and diarrhoea. The patients 
rapidly lose flesh and strength until convulsions or coma take 
place, sometimes preceded by acute mania, and death. To 
this disorder Delafield gives the name of acute productive 
nephritis. 

Duration. — In cases due to exposure the duration varies 
from a few days to three or four weeks. Post-scarlatinal cases 



ACUTE POST-SCARLATINAL NEPHRITIS. 



125 



may persist four to eight weeks. In other fevers the course 
is much more rapid. 

Occasionally the disease takes the form of exacerbations 
and remissions extending over several weeks. 

Prognosis. — Usually favorable; least favorable in scarlet 
fever cases in which one-third are fatal. 

Dangers. — Suffocation from hydro thorax and pressure on 
the lungs or from oedema of the glottis or lungs ; uramia 
with high temperature and cardiac paralysis ; inflammations 
of internal organs, secondary pneumonia, rarely pericarditis 
and peritonitis ; inflammation of the skin (from oedema) with 
septicaemia ; development into chronic nephritis. 

Cases of suppression of urine lasting from twenty-four to 
forty -eight hours usually terminate fatally. 

Having considered acute glomerulo-nephritis in general, let 
us now glance at acute nephritis as it manifests itself in 
various diseases. 

ACUTE POST-SCARLATINAL NEPHRITIS. 



Pathology. — The most frequent type is, as a rule, a glom- 
erulo-nephritis, but glomerular changes are not a necessity % 
In some cases an acute interstitial variety is found. Conges- 
tion of the vessels and fatty degeneration of the epithelium 
are present in practically all cases. If death occurs early the 
kidney shows very slight macroscopic changes ; if death has 
occurred at the height of the disease the kidney is usually 
enlarged, flaccid and either pale or red from haemorrhages or 
congestion. 

Clinical Features. — The symptoms begin anywhere be- 
tween the fourteenth and twenty-second day of the fever. 
There is a slight rise of temperature, puffiness under the eyes, 
frequency of urination which is sometimes painful, and slight 
pain in the back ; oedema increases until general dropsy is 
present, with difficulty of breathing, dimness of vision, waxy 



126 INFLAMMATIONS OF THE KIDNEY. 

pallor, anaemia, vomiting, drowsiness, and stupor. The urine 
decreases in quantity and contains albumin, blood, and casts. 
In severe cases there is rapid diminution in the volume of the 
urine until suppression takes place, followed by coma or con- 
vulsions. 

The Urine. — Micturition. — Frequent. 

Quantity of Urine. — Decreased. In severe cases may be 
only six or eight fluid ounces per twenty-four hours, or sup- 
pressed entirely. Frequently less than a pint. 

During convalescence slight polyuria, one hundred fluid 
ounces (3000 c. c.) in twenty-four hours possible. 

Color. — High colored, opaque, dirty-red (smoky) from 
blood. 

Reaction. — Acid. 

Specific Gravity. — Usually 1.020, but may be higher. 

Urea. — Grains per ounce : increased ; grains total : de- 
creased. 

Chlorides. — Diminished. 

Uric Acid. — Increased, relatively. 

Albumin. — Abundant : Fifth mark on Ksbach tube, or 
even much more possible. May be small or even absent at 
first ; may disappear temporarily ; may persist after other 
symptoms disappear. 

Sediment. — Abundant : casts abundant ; hyaline first then 
epithelial, leukocyte and blood casts plenty ; granular casts 
present ; a few fatty. Blood corpuscles and shadows, pus 
corpuscles, renal epithelium, uric acid, urates. 

Prognosis. — Two cases out of three recover, but the 
prognosis in any case depends upon various conditions. In 
severe cases death may take place on the second or third day. 

Favorable Signs. — Urine less dark and less scanty before 
end of first week, and at end of two weeks quantity of urine 
not much below normal, and at end of four weeks but little 
albumin. A trace of albumin may be present for months and 
finally disappear. 



ACUTE POST-SCARLATINAL NEPHRITIS. 127 

Unfavorable Signs. — Severe symptoms early in the case ; 
suppression of urine or scanty, bloody urine early. If 
granular and fatty casts are numerous at end of sixth to 
eighth week, chronic nephritis is likely to ensue. Numerous 
pus corpuscles in the sediment are thought a bad sign. 

In scarlatinal cases it is noticed that recovery sometimes 
takes place even when uraemia, anuria, and pulmonary 
oedema occur ; on the other hand, death may unexpectedly 
occur in spite of apparently unimportant symptoms. 

Convulsions early in the case and numerous large, dark, 
granular and especially waxy casts with a high percentage of 
albumin have been noticed by the writer in fatal cases. 

Fiirbringer has noticed that in the majority of his fatal cases 
the urine was only slightly or not at all hemorrhagic. An 
increase in the dropsical symptoms with small, rapid low- 
tension pulse, and increasing albumin in the urine, are grave 
symptoms. Scarlatinal nephritis should show an improve- 
ment in from seven to ten days, but complete recovery has 
been known after eight or ten weeks, and it is claimed even 
after a year. 

Duration. — Under favorable circumstances improvement in 
a week or ten days, and recovery takes place in about four 
weeks. As a rule, if the disease lasts six months it is to be 
regarded as chronic. Albumin may leave the urine in favor- 
able cases entirely at the end of four weeks. The writer has 
seen cases where a trace persisted for five or six months with- 
out development of chronic nephritis and with subsequent 
complete recovery. 

The Dangers are, (a) extension of dropsy to chest with pul- 
monary oedema ; (b) anuria and uraemia ; (c) cardiac failure ; 
(d) chronic nephritis with retinitis ; (e) extensive inflamma- 
tion of external organs. Removal to a hot climate during or 
just after convalescence will sometimes prove to be beneficial. 

The Important Complications are pericarditis, retinitis and 
serous inflammations, diffuse bronchitis and a peculiar pneu- 
monia midway between catarrhal and croupous. 



128 INFLAMMATIONS OF THE KIDNEY. 

ACUTE NEPHRITIS IN VARIOUS DISEASES. 

In measles it is rare. We find the usual cloudy swelling and 
fatty change in the tubular epithelium, also degenerative 
changes in the capsule. Clinically, it resembles post-scarla- 
tinal. The nephritis of chicken-pox is like that of scarlet fever. 
It is rarely seen. Dropsy and fatal uraemia may occur. It 
may be latent, slight or serious. Acute nephritis is also rare 
in influenza. If present is either degenerative or glomerular, 
rarely haemorrhagic. In erysipelas nephritis occurs in about 
five per cent, of the cases. In such cases fever and the skin 
affections disappear quickly. Occasionally erysipelas nephri- 
tis runs a slow course, or may even become chronic. In 
malaria the general appearance of the kidney suggests the 
action of a toxic rather than of an organized agent. In acute 
cases there is, as a rule, no macroscopic change in the kidney. 
Microscopically we find pigmentation of the glomeruli and at 
times of the inter-tubular capillaries. The malarial parasites 
are common in the capillaries of the stroma. Capsular epithe- 
lium undergoes degeneration and desquamation, and an albu- 
minous exudate is present in the capsular space. The epithe- 
lium of the convoluted tubules is likewise degenerated, and 
tube-casts are numerous. The nephritis has a tendency to 
become chronic and to develop into contracted kidney. 

In small-pox a great quantity of blood may be found in the 
urine, but, according to Rosenstein, the source of it is more 
frequently in the renal pelvis. 

Whooping-cough is sometimes attended by acute nephritis, 
which may terminate fatally. 

In infectious sore throat there may be acute nephritis with 
dropsy, but it is rare. 

Acute arthritis rarely may be followed by acute nephritis, 
which occasionally is severe or fatal with intense albuminuria 
and cedema. 



ACUTE DIPHTHERITIC NEPHRITIS. 129 

ACUTE DIPHTHERITIC NEPHRITIS. 

Pathology. — There are no characteristic lesions. Degen- 
erative changes in the epithelium are always present, fre- 
quently with more or less pronounced alterations in the inter- 
stitial tissue (accumulations of plasma-cells) and in the 
glomeruli. Glomerulo-nephritis is especially common in 
older children and in cases of prolonged duration. The 
lesions are not due to bacteria but to toxic substances in the 
blood. The diphtheria bacillus may, however, be present in 
the kidney on culture. 

Councilman has found acute interstitial nephritis to occur 
in diphtheria 24 times in 103 cases. (See Acute Inter- 
stitial Nephritis.) 

Clinical Features. — The nephritis appears in the majority 
of cases at the acute period of the diphtheria. The urine oc- 
casionally, but not usually, contains blood and the patient is 
seldom dropsical. Anuria and uraemia are not common. 
Characteristic pathognomonic renal symptoms are usually 
wanting and for this reason the renal lesion is often un- 
recognized. There is sometimes, however, an enormous 
amount of albumin, as much as two per cent, by weight, in 
the urine. Degenerated renal epithelium is abundant in the 
sediment, but red blood corpuscles not so. The casts and 
cylindroids have a peculiarly opaque appearance in conse- 
quence of epithelial debris. The course of the disease is less 
variable than that of scarlatinal nephritis and rapid recoveries 
from even severe cases are not uncommon. Cases which 
have lasted for years have been known to recover. 

The writer has seen several cases, all of which proved fatal, 
though in some the death was not attributed to the renal 
lesion. 

ACUTE NEPHRITIS IN PNEUMONIA. 

Pathology. — There is nothing characteristic in the pa- 
thology. Degenerative changes — cloudy swelling and fatty 
9 



130 INFLAMMATIONS OF THE KIDNEY. 

changes — are found in the epithelium of the convoluted 
tubules. The glomeruli are usually intact. Haemorrhages 
are not infrequently present. The renal changes are not due 
to the pneumococcus, but the result of its toxin. The previous 
existence of renal disease usually brings about a fatal termina- 
tion in pneumonia, but the acute nephritis of pneumonia is 
seldom fatal. Acute interstitial nephritis sometimes occurs 
in pneumonia. 

Clinical Features. — The nephritis usually begins on the 
third to the sixth day, or from the fourth to the eighth of the 
disease, and is characterized by the presence of albumin and 
casts in the urine, and sometimes of blood. In the writer's 
experience the casts seen have been usually granular and dark 
granular, as in acute parenchymatous nephritis. If the patient 
recover the nephritis may disappear, but occasionally it be- 
comes chronic. (The presence of a slight acute parenchy- 
matous nephritis is noticed in many cases of pneumonia by 
the occurrence of a slight albuminuria, which disappears as 
the patient recovers.) 

As a rule, the acute nephritis of pneumonia remains intense 
only about a week, and in no way influences the primary dis- 
ease. CEdema is said sometimes to be present. The progno- 
sis is usually favorable. 

ACUTE NEPHRITIS IN TYPHOID FEVER. 

Pathology! — The kidney is enlarged and congested, and 
the seat of punctiform haemorrhages. Cloudy swelling and 
fatty changes in the convoluted tubules and loops of Henle 
are present. In rare cases there is a distinct glomerulo- 
nephritis. 

Clinical Features. — The slight acute parenchymatous ne- 
phritis, whose only feature is albuminuria, with or without 
cylindruria, is common in typhoid as in other fevers. Osier 
found it in forty-six out of seventy-five cases of typhoid. 



ACUTE NEPHRITIS IN YELLOW FEVER, ETC. 131 

More rarely a genuine acute haemorrhagic nephritis occurs 
with fever, backache and scanty albuminous, bloody urine. 
Osier found this form in two out of seventy-five cases of 
typhoid. It may occur in the beginning of the disorder, 
masking for a time the true nature of the malady, or at the 
end of the first or second week. Dounadieu reports a case in 
which with scanty, highly albuminous urine there was very 
pronounced dyspnoea, signs of pulmonary oedema, incessant 
vomiting, delirium and a relatively low temperature. The 
renal symptoms gradually subsided, and the temperature 
crept slowly up. 

More common but less serious is a mild form during con- 
valescence. It develops after the fall of the fever, and is 
usually associated with oedema. 

Sometimes it may happen that after the temperature seems 
to have fallen definitely it rises again. In such cases the 
urine should be carefully examined for signs of nephritis. 

THE ACUTE NEPHRITIS OF YELLOW FEVER, CHOLERA, AND 

THE PLAGUE. 

In yellow fever nephritis the kidney is normal in size or 
slightly enlarged and the color pale-yellow or unaltered. The 
microscopical feature is extensive fatty change in the epithe- 
lium of the tubules. 

In cholera, if death occurs not early, the kidney has a 
violet hue, and later still, is slightly yellowish. On section 
the organ has a sticky glabrous feel which is deemed of con- 
siderable diagnostic importance. The causes of the renal 
changes are probably due both to the profound depression of 
the circulation and to the cholera toxin. The urine is fre- 
quently totally suppressed ; if any is voided it contains albu- 
min, ammonia, and acetone. Indican and ethereal sulphates 
are increased. 

In the plague nephritis is common in severe cases, but is 



132 INFLAMMATIONS OF THE KIDNEY. 

not peculiar to the disease. The usual features of acute dif- 
fuse nephritis are found in the urine, but the presence of blood 
is said to be due to lesions in the lower parts of the urinary 
tract. 

ACUTE NEPHRITIS IN GASTRO-ENTERITIS. 

Koplik has noticed that nephritis frequently complicates 
gastro-enteritis in children, at least in serious cases, and calls 
attention to three symptoms which should attract the attention 
of the physician : 

i. Restlessness; incoercible and persistent vomiting, and 
cutaneous oedema. Restlessness of ursemic origin is char- 
acterized by its persistency and by its alternation with periods 
of stupor. 

2. Vomiting of renal origin is not affected by washing out 
the stomach nor by a strict diet, distinguishing it from that 
of gastric origin. 

3. The oedema is less apparent than in Bright's disease in 
adults, and it may be overlooked if not sought for. The an- 
terior parts of the lower limbs and dorsa of the feet are the 
places of predilection. To dent the flesh one must press 
down forcibly. 

Children with such symptoms present albuminuria, casts, 
renal epithelia and red blood corpuscles. The quantity of 
urine is also more or less diminished. The outlook is favor- 
able if the toxins be eliminated by energetic and appropriate 
treatment. Therapeutically, he advises washing out the 
stomach and rectum several times a day with a solution con- 
taining 4 per cent, of sodium chloride and 3 per cent, of 
sodium carbonate, leaving some in the intestine to be absorbed 
to stimulate the kidneys. In more serious cases he injects 
two hundred cans, hypodermically. During the whole 
period the child is fed on albumin-water diluted with lime- 
water. Internally he employs the subnitrate of bismuth in 
large doses. (Hahn. Monthly from La Settimana Medica.) 



ACUTE NEPHRITIS FROM EXPOSURE, ALCOHOLISM, ETC. 133 



ACUTE NEPHRITIS FROM EXPOSURE TO COLD, ETC. 

This form or that due to unknown causes may appear 
rather suddenly without any demonstrable cause, or it may 
follow a marked chill. The features are often as follows: 
Chill, fever, pain in back and in bladder, difficult and frequent 
micturition, diminished volume of urine, dropsy ; in severe 
cases these initial symptoms are followed by cerebral symp- 
toms, coma or convulsions in from twenty-four to thirty-six 
hours, albuminous urine, etc. 

CBdema may be absent in some cases, but usually dropsy 
appears in a few days after the initial chill. The prognosis 
is usually favorable, and development of chronic nephritis un- 
likely. In some cases blood appears in the urine from time 
to time for months. Sometimes the first symptom is vomit- 
ing, in other cases oedema or puffiness of the face and slight 
dyspnoea due to hydrothorax. The course may be either 
mild or severe ; in mild cases there is but slight oedema and 
not an excessive amount of albumin and blood in the urine. 
In severe cases there is much blood in the urine with great 
general dropsy and uraemia. In the severe cases death may 
take place in three or four weeks or sooner. Recovery, how- 
ever, has been known from even the severest cases. After an 
apparent recovery there may be a relapse weeks or months 
later. In such a case the term acute recurrent nephritis is 
used. 

In the cases of unknown origin there is frequently septic 
infection of some sort as from a mild sore throat, or insignifi- 
cant gastro-intestinal disorder, or from slight purulent -affec- 
tions as boils or eczema. 

ACUTE ALCOHOLIC NEPHRITIS. 

This occurs especially among brewers and heavy, beer 
drinkers. It may be -favored by exposure to cold, but is 



134 INFLAMMATIONS OF THE KIDNEY. 

essentially toxic from alcohol. The features are a rapid and 
great development of general dropsy, a diminished and highly 
albuminous urine, which, however, seldom contains blood. 
Recovery is possible, but there is danger of the disease becom- 
ing chronic. 

Prognosis. — As a rule, the prognosis in the numerous dis- 
eases mentioned above is favorable, i. e., disappears on re- 
covery from the primary disorder. Scarlet fever nephritis is 
of course an exception. Fatal cases of acute nephritis have 
been known to occur from measles, chicken-pox, whooping- 
cough. Chronic cases have been known to develop from ery- 
sipelas, malaria, and pneumonia as well as from other dis- 
eases. 



ACUTE INTERSTITIAL NEPHRITIS. 

The non-suppurative form of this lesion has been studied by 
Councilman, Biermer, Klein, Friedlander and Sorensen. 

Definition. — An acute inflammation of the kidneys affect- 
ing principally the interstitial tissue or stroma, which is af- 
fected by general and focal infiltration with cells which 
correspond to those known as Unna's plasma cells. 

Etiology. — It is frequently the result of acute infectious 
diseases, particularly those of childhood. Councilman found 
it 24 times in 103 cases of diphtheria, and 5 times in 20 cases 
of scarlet fever. It also occurs in measles, pneumonia, 
whooping cough, acute endocarditis, and epidemic cerebro- 
spinal meningitis. It occurs in scarlet fever which is accom- 
panied by diphtheria. Bacteriologic examination of the kid- 
neys has for the most part proved negative in cases of acute 
interstitial nephritis. 

Pathologic Anatomy. — The Kidneys. — Normal in size or 
but slightly enlarged. Sometimes two or three times normal 
in weight 

The Capsule. — Distended. Strips easily. 



ACUTE INTERSTITIAL NEPHRITIS. 



135 



The Surface. — Pale-grayish, opaque, somewhat like amy- 
loid kidney, mottled with irregular hyperaemic areas. 

The Stellate Veins. — Injected and often surrounded by 
small opaque nodules. 

Section. — Shows normal markings obliterated and the con- 
trast between medulla and cortex obscured. 

The Cortex. — Greatly increased in width — to three or more 
times the normal. 

The Glomeruli. — Not prominent, and usually invisible. 

The Surface of Section. — Grayish and opaque, and marked 
with small hyperaemic and ecchymotic areas. 

The Pyramids. — Darker than the cortex. Areas more 
opaque than the general cut surface are seen extending in 
lines from the pyramids through the cortex. 

The Renal Tissue. — Soft, friable, moist, and on pressure 
exudes an opaque milky fluid. The same may be scraped 
from the surface with the knife. 

The changes are often most marked at the bases of the 
pyramids in the intermediate zone. At times there is a strik- 
ing discrepancy between the macroscopic and microscropic 
changes. 

Pathologic Histology. — The feature is an intense cellular 
infiltration in the interstitial tissue or stroma, particularly 
marked at the bases of the pyramids, the border zone beneath 
the capsule and about the glomeruli. The cells are identical 
with Unna's plasma cells. The tubules are widely separated 
by areas of interstitial tissue, and their epithelium presents 
various degrees of degeneration. The glomeruli show no 
essential changes apart from periglomerular accumulation of 
of plasma cells. 

Clinical Features. — About the only clinical feature noticed 
by Councilman has been albuminuria. Biermer has noticed 
renal symptoms two weeks before death, namely, diminished 
urine, dropsy and uraemia. Sorensen noticed slight oedema 
and ascites in one case, that of scarlet fever with severe septic 
diphtheria. 



136 INFLAMMATIONS OF THE KIDNEY. 

The course is rapid, and in some cases the urine becomes 
normal before death from the primary disorder takes place. 

TREATMENT OF ACUTE NEPHRITIS. 

The modern view of the treatment of acute nephritis is 
based essentially on an effort to rid the body of the noxious 
materials which are causing the inflammation. With this 
end in view, (i) the diet is to be such as to cause the least 
irritation to the kidneys by curtailing the supply of toxins ; 
(2) the kidneys are to be flushed with large amounts of water 
taken internally ; (3) the colon flushed to remove intestinal 
toxins and also to stimulate the activity of the kidneys ; (4) 
and the skin rendered active by hot baths or packs. Com- 
paratively little value is attached to the use of drugs, which, 
if given at all, should be for certain special purposes and in 
carefully regulated doses. 

The details of the treatment are as follows : 

In scarlet fever cases milk diet throughout the fever, rest 
and avoidance of the slightest chill will sometimes prevent 
the onset of nephritis. 

When premonitory symptoms show themselves by marked 
increase in arterial tension or presence of blood in the urine, 
a saline cathartic, in case of children fluid magnesia, will 
sometimes avert the onset of the disease. 

If, however, the disease is thoroughly established, the fol- 
lowing measures must be adopted : 

Diet. — As a general thing well-boiled milk is to be pre- 
ferred for diet ; one and a half to two quarts daily may be 
given at frequent but regular intervals, and taken in small 
quantities at a time, not swallowed in large amount. 

The milk may be mixed according to the taste of the patient 
with weak tea or coffee, with plain soda water, French Vichy 
or lime water ; a little salt or a few drops of brandy may be 
added to it, or it may be mixed with arrow-root gruel. When, 
however, the urine is nearly or wholly suppressed the patient 



GENERAL HYGIENIC MEASURES IN ACUTE NEPHRITIS. 137 

must live on arrow-root gruel only, for the time being. After 
improvement sets in fresh buttermilk, milk-gruel with rice, 
flour-gruel, malted milk, Kumyss, barley-water and oatmeal 
water are allowable, and usually after a week or ten days clear 
vegetable soups, light broths from pigeon, fowl or veal, and 
even eggs may be allowed but no meat extracts should be 
given. 

At the end of two or three weeks, usually, it will be allow- 
able to give solid foods ; rice may be taken in form of thin 
broth or plain pudding, bread and butter, lettuce, water-cress, 
sweet potatoes, grapes and oranges. If albumin in the urine 
is in large amount and not decreasing, defer giving solid foods 
until improvement is noticed. 

Thirst is often a feature of the disease, and the patient 
should be given an abundance of fluids not only for relief of 
the thirst but also as a therapeutic measure. As much as five 
or six quarts of water a day may be needed, and it is best 
given hot. If the thirst is excessive it may be relieved by 
giving a pint of water boiled and cooled, containing one 
drachm (4 grams) of cream of tartar together with the juice of 
half a lemon. 

When nausea or vomiting is a feature the patient may be 
unable to take liquids in any considerable amount. In such 
cases they must be given him in teaspoonful doses every five 
to fifteen minutes until the stomach tolerates larger amounts, 
even when coma or convulsions are present. 

General Hygienic Measures. — The patient is to be kept in- 
doors throughout the whole course of the disease, clothed in a 
woollen night-dress, and kept quiet, in a room of the tempera- 
ture of 72 ° F. 

Good ventilation is desirable, but on no account is the pa- 
tient to be exposed to draughts. 

Albuminuria and haematuria are known to be aggravated in 
cases where the patient is allowed to get out of bed incau- 
tiously without regard to the temperature of the room. 



138 INFLAMMATIONS OF THE KIDNEY. 

As long as albumin in appreciable quantity is found in the 
urine it is prudent to keep the patient indoors. 

Bathing. — The patient is to have a tepid bath in water of 
a temperature of 95 ° F., twice a day, morning and evening. 
The duration of the bath is not to exceed fifteen minutes. 
He is to be rubbed with a dry, warm towel, after which he is 
to put on a warm night-gown and return to a bed warmed 
with hot water bottles. His bed -room should adjoin the bath- 
room. In some cases it is better to wash the skin every day, 
one member at a time in tepid water, and rub dry. 

Adults may usually be put into a hot bath for fifteen or 
twenty minutes then rubbed dry. 

In cases of ursemia the hot wet pack or hot air bath may 
be necessary . (See further on.) 

Care of the Bowels. — It must be the rule that the patient 
have a thorough movement at least once a day, but active 
purgation is usually to be avoided. Obstinate constipation 
may require thirty grains of jalap or T \ grain of elaterium. 

As a rule, when necessary, the so-called drastic cathartics 
are preferable, as senna, Epsom salt, gamboge, etc. 

Instead of cathartics high flushing of the colon every four 
hours is to be remembered, followed by rectal injection of a 
pint of normal salt solution which should be retained. The 
records of Cook County Hospital, reported by Dr. F. W. 
Wood, show the beneficial effects of this treatment : 

CBdema of the extremities rapidly disappears, headache and 
backache cease to annoy, the mind clears, the appetite is 
stimulated, and, best of all, the whole intestinal tract becomes 
active, so that toxic elements, which are said to play so im- 
portant a role among the etiological factors of nephritis, are 
quickly and efficiently eliminated. This is accomplished, too, 
without the use of active cathartics, which are certainly open 
to some objections. The cases reported by Dr. Wood also 
show that we may expect to obtain from this simple adjuvant 
treatment marked diuretic effects. The amount of urine 



SYMPTOMATIC TREATMENT OF ACUTE NEPHRITIS. 139 

passed in some of his cases reached 156 ounces during the 
twenty -four hours. It does not seem to matter whether the 
acute nephritis is a complication of one of the infectious dis- 
eases or not ; in either class of cases colonic flashings are use- 
ful. — {Hahn. Mo7tthly.) 

The writer has, however, seen in private practice several 
cases where children would not tolerate such vigorous meas- 
ures, and the physician attempting them was dismissed and 
some one else called in. 

Symptomatic Treatment. — Aconite. — In post-scarlatinal 
cases or those due to exposure to cold ; early stages 
where there is either a bounding pulse and hot skin, or a 
tense small pulse and cool surface of the body. The patient 
is anxious and there is irritability of the stomach. There is 
rapid development of anasarca, restlessness and soreness in 
the lumbar region. 

Use the first decimal, or ten drops of the tincture in four 
ounces of water, a teaspoonful every two hours. 

Apis. — When dropsy is a feature, especially about the face 
with headache early in the case and severe, use Apium virus, 
third decimal. Apis in the third decimal has recently been 
reported to have cured in eight days a girl of 18 years. The 
symptoms were greatly swollen face, skin tense and pale, pit- 
ting on pressure ; general anasarca, rapid, strong heart action, 
and albuminous urine. The remedy was given in doses of 
three drops every two hours, with rest in bed and milk diet. 
Symptoms calling for this remedy are rapid development of 
anasarca, sudden swelling, generally first on the eyelids ; 
cedematous parts have a waxy hue ; there is backache, head- 
ache and aching of the limbs, but no thirst. There is great 
dyspnoea and suffocative constriction about the throat. The 
mental condition is torpid. If convulsions occur they are 
tonic and clonic. There is aggravation the latter part of the 
night, and relief from sitting erect. 

Cowperthwaite gives this remedy first place in acute ne- 
phritis, and uses the third decimal. 



140 INFLAMMATIONS OF THE KIDNEY. 

Arsenicum. — Useful in subacute cases slow to recover, 
tendency toward the chronic ; the patient is pale, waxy, 
anaemic, restless, has difficulty of breathing, especially about 
midnight, is dropsical, has extreme thirst for small quantities, 
and is very weak. The stomach is very irritable, with con- 
stant burning, and a feeling of pressure. The pulse is small, 
rapid and weak, and there is dyspnoea and symptoms of pul- 
monary oedema. Use the second or third decimals, or drop 
doses of Fowler's solution every four to eight hours. 

Arsenite of copper is recommended by Goodno for uraemic 
conditions. Dose three grains of the second or third decimal 
every half an hour to two hours. The remedy possesses a 
most remarkable influence over uraemic convulsions, improve- 
ment being usually apparent in from two to four hours. 

Apocynum can. — Acute nephritis with scanty, dark urine, 
great thirst but nausea from drinking water, feeling of oppres- 
sion about the epigastric region and the thorax; irregular, 
feeble, intermittent pulse ; stupor with mechanical move- 
ments of one arm or leg. Useful in cases of dropsy, which 
may be treated with liberal doses of the tincture or infusion. 
Children should be given two-drop doses of the tincture, 
which may be increased if necessary until nausea is com- 
plained of. 

Belladonna. — Fever, flushed face, headache, vomiting, 
scanty, bloody urine. Following Aconite in early stages. 
Suited to congestion of the glomerular capillaries. Use 
second or third decimal, not the tincture. 

Cantharides. — After fever has subsided but urine is still 
scanty, bloody, and highly albuminous, voided in small 
quantities with pain and straining. Use the first decimal or 
even drop doses of the tincture, three to eight times daily. 
Useful in those cases wherever abnormally concentrated 
urine causes frequent micturition with a disagreeable, painful 
sensation. There is burning, stinging, and tearing pain in the 
region of the kidneys, pain in the loins, and over the abdo- 



SYMPTOMATIC TREATMENT OF ACUTE NEPHRITIS. 141 

men. The remedy is suited to uraemic conditions, delirium 
and coma with a high fever and full, hard pulse. Cowperth- 
waite uses the third decimal. 

Cicuta virosa. — The principal indication for this remedy is 
the subsultus tendinum so often observed in uraemic condi- 
tions. 

Helleborus niger. — Violent pains in the head, mental tor- 
por, imperfect vision, nausea, vomiting, dropsical conditions, 
with frequent desire to urinate. Serviceable in dropsy with 
scanty high colored urine. Give five drop doses of the tinct- 
ure in water every two or four hours. It is one of the in- 
gredients of Macy's diuretic mixture. 

Ferrum. — This, in the writer's experience, is a most useful 
remedy in lingering cases where long-continued anaemia and 
weakness are the features. It may be given to children in the 
form of the phosphate or iodide. Stubborn cases may re- 
quire teaspoonful doses of Basham's mixture in plenty of 
water or the same of Boudreaux's syrup, four times daily, 
but not when headache and constipation are present or there 
is a high-tension pulse. 

The indications for the remedy are anaemia with pale face 
and lips and great debility ; pallor of the mucous membranes, 
especially that of the buccal cavity ; bellows-sound of the 
heart, and anaemic murmur in the arteries and veins ; the 
muscles are feeble and easily exhausted from slight exertion ; 
there is oedema of the body. 

The above is a truthful picture of many cases which the 
writer sees and which are materially helped by the administra- 
tion of iron. It is hardly a remedy for acute nephritis, but 
the writer has seen cases where this disorder merged into the 
subacute form rapidly (in three weeks) and all the indications 
for iron appeared. 

Jaborandi. — This drug is valuable when uraemic symptoms 
are alarming. (See Special Therapeutic Measures.) 

Mercurius diricis. — This is a valuable remedy when there 
is severe headache, nausea and vomiting. 



142 INFLAMMATIONS OF THE KIDNEY. 

Mercurius cor. — Long lasting cases after dropsy is gone ; 
the patient looks badly, is anaemic, has dyspnoea on exertion, 
frequency of micturition; especially useful when there is diar- 
rhoea with tenesmus and albuminous urine. Use third deci- 
mal or higher. Searle, of Brooklyn, has advised Merc. cor. 
as the main remedy in acute nephritis, alternating it with 
Aconite or Ferrum phos., and in conjunction with warm baths 
(of temperature 98 ° to ioo°) prolonged half an hour to one 
hour. 

The remedy is suited to inflammations and acute conges- 
tion of the kidney. The urine is scanty or completely sup- 
pressed, very dark and contains albumin, blood corpuscles, 
granular and fatty casts. The late Dr. Millard used Merc, 
cor. in alternation with Cantharides for routine treatment in 
acute nephritis. 

Rhus tox. — Suited to cases after the subsidence of the 
initial stages, when pain in the back is a feature, with gen- 
eral soreness or aching, but no dropsy. Useful in cases due 
to exposure and in some post-scarlatinal cases. Goodno uses 
the tincture in one-fourth drop doses hourly. Cowperthwaite 
uses the third decimal. 

Terebinthina. — Fever, dyspnoea, headache and scanty, 
bloody urine. Dropsy may be absent, and, as a rule, uremic 
symptoms are not marked. It is especially useful in acute 
nephritis from colds or malarial poisoning. The writer finds 
this the best general remedy for hemoglobinuria, and uses the 
first decimal. Cowperthwaite advises the second decimal in 
acute nephritis. 

Veratrum viride. — This is a remedy for the early stage of 
acute nephritis when congestion is the feature, high arterial 
tension, high temperature, or thin small pulse with trouble- 
some vomiting. It is suited to the cerebral congestion and 
convulsions of the early stage, or during the course of acute 
nephritis. 

Other remedies which may be indicated are Phosphorus, 



SPECIAL THERAPEUTIC MEASURES IN ACUTE NEPHRITIS. 143 

Digitalis, Bryonia, Cannabis Ind., Hepar, Secale, Sabina, 
Scilla, Chelidonium, Colchicum, Veratrum album, Anti- 
monium tart, Nitric acid, Glonoin. 

The writer uses Aconite, Belladonna, Cantharides, Tere- 
binthina, Arsenicum and Ferrum usually progressively in 
the order named, when the case has a typical course. 

Special Therapeutic Measures. — As a rule careful nursing 
and proper observance of hygienic and dietetic precautions 
are all that are needed in a case of acute nephritis, but symp- 
tomatic treatment should be employed with the hope of short- 
ening the course and preventing the lapse into the chronic 
form. Vigorous measures, especially catharsis and active 
diuresis, are not advised so long as the case is doing well. 
Severe and dangerous symptoms may, however, require cer- 
tain palliative measures which will be described as follows : 

Pain in the back is sometimes severe in the onset of the dis- 
ease and may possibly require cupping, but only when 
severe. Dry cups are used in the case of children, and wet in 
the case of adults. Warm poultices may also be applied to 
the region of the kidneys. In some cases counter-irritation 
may be necessary, as with mustard. 

Internally Rhus tox., Oil of sandalwood, Pichi or Can- 
tharides may be indicated. In severe cases of backache in 
acute nephritis from exposure the tincture of Rhus tox., ten 
drops in four ounces of water, teaspoonful hourly, is a 
favorite prescription. 

Dry skin and lack of perspiration may aggravate the case ; 
for this it may be necessary to use the hot air bath. In obsti- 
nate cases it may be necessary to start the perspiration with 
Jaborandi or Pilocarpine, and then promote it with hot packs 
or baths. In the case of children two to five grains of the 
second decimal trituration of Pilocarpine may be given every 
two hours until perspiration is established. 

If the urine is suppressed more vigorous measures will be 
necessary. (See next paragraph.) 



144 INFLAMMATIONS OF THE KIDNEY. 

In some cases the Spirit of Mindererus, a solution of am- 
monium acetate, may cause diaphoresis when given in doses 
of half an ounce diluted with water. In cases where there is 
fever this remedy and Aconite may prevent the vasoconstric- 
tion which precedes uraemia. (Anders.) 

Treatment of Uraemic Convulsions. — This varies according 
to the age of the patient and the severity of the convulsions. 
When the patient is a child and the urine is very scanty or 
suppressed and the uraemic symptoms, headache, vomiting, 
and twitchings forbode convulsions, the hot, wet pack should 
at once be used. 

Tooker's method of giving the hot pack to young children 
with suppression of urine and uraemic symptoms is as follows : 

Spread the bed with several layers of woollen blankets. 
While the child is being stripped, wring out a cotton sheet 
which has been immersed in a bucket of boiling water. 
Spread the sheet quickly on the open blankets and wrap up 
the child in it, leaving only head exposed. Bring over the 
blankets and tuck in all around as snugly as possible. Place 
a cloth wet in cold water on the child's head, and leave there. 
The pack should last from fifteen to twenty minutes to an 
hour ; if the child goes to sleep, leave undisturbed until it 
awakes. When taken out, give a cool sponging. 

In cases where there is great dyspncea or signs of cardiac 
weakness the hot air bath should not be used at all, but 
merely warm baths or a very short wet pack. 

In cases where it is feasible colon flushing with injectio7i of 
normal salt solution, as suggested by Dr. Wood, of Chicago, 
should be tried. A pint of warm, normal salt solution is in- 
jected, per rectum, after colon flushing, three or four times 
daily. 

Hot linseed-meal poultices, containing a tablespoonful of 
mustard, may be applied to the region of the kidneys every 
four hours. 

In desperate cases subcutaneous injections of a quart of 



TREATMENT OF UREMIC CONVULSIONS. 



145 



normal salt solution every six to twelve hours may be tried. 

The principal drug in cases of uraemic convulsions is Pilo- 
carpine hydrochlorate, use of which must be made with great 
care. The writer is fully aware that a good many large 
hypodermic doses of this agent have been given without 
apparent harm. At the same time it is well to bear in mind 
the fact that untoward accidents from administration of it are 
known to have occurred. 

In the writer's opinion the dose and method of administra- 
tion of the drug should be varied according to circumstances. 
In cases where the convulsions are severe and repeated it may 
be necessary to give a hypodermic dose of Pilocarpine as 
large as one-quarter of a grain, followed in twenty minutes 
by another. If, as a result, there are signs of cardiac depres- 
sion a hypodermic of brandy or ether should be given at once, 
as suggested by Shattuck. Lastly the hot air bath should be 
administered to promote the perspiration caused by the Pilo- 
carpine. 

In the case of slight convulsions one-twelfth of a grain of 
the drug hypodermically, followed in three hours by another, 
and the hot air bath may be sufficient. If two hypodermics of 
one-twelfth do not start the perspiration two more may be 
given within the next eighteen hours. After the patient is 
conscious and has perspired freely tablets of the drug may be 
given by the mouth so that the patient takes in all one-twelfth 
of a grain a day for a few days. 

When convulsions have not yet occurred, but are feared in 
consequence of marked uraemic symptoms (headache, vomit- 
ing and twitchings), Pilocarpine may be administered either 
as above or in the following manner : 

Use the first decimal dilution, one teaspoonful in half a 
glass of water, of which mixture the dose is a teaspoonful 
every fifteen minutes until perspiration occurs, then every 
hour for forty-eight hours. Owing to its depressing action it 
is advisable to follow it with Digitalis tincture, fifteen minims 
10 



146 INFLAMMATIONS OF THE KIDNEY. 

in half a glass of water, of which the dose is a teaspoonful 
every hour until the heart's action is improved. 

In the case of convulsions in children dry cupping of the 
loins, the wet pack and a brisk purgative may be all that is 
required without the use of Pilocarpine. In the case of adults, 
Chloroform, hypodermics of Pilocarpine, and in robust, red- 
faced or cyanotic patients venesection (withdrawal of twenty 
ounces of blood) are recommended, or colon flushings with in- 
jection of normal salt as above. 

Inhalations of Amyl nitrite are sometimes serviceable in 
convulsions. Rectal enemas containing ten to twenty grains 
of Chloral Hydrate and twenty to sixty of Potassium Bromide 
may be used. 

For catharsis in uraemia the most efficient agents are 
elaterium or croton oil, the latter in one-half drop doses, re- 
peated every hour until the bowels are moved. The oil may 
be rubbed up with a small powder of sugar of milk and placed 
on the patient's tongue, even if he is unconscious. Oxygen 
inhalations, and sometimes caffeine hypodermically, may be of 
service in convulsions. 

The saline diuretics, notably acetate and citrate of potas- 
sium^ may sometimes be useful in acute nephritis. The 
writer has given the citrate in ten grain doses in water to 
young children and larger doses to adults. When the salines 
cause nausea they should be immediately discontinued. The 
acetate of potassium may be given in doses of sixty to ninety 
grains in twenty-four hours. Rectal injections containing 
this drug may be useful. 

The treatment of drowsiness or coma is substantially the 
same as that of convulsions. These features sometimes yield 
to tepid baths, followed by cold showers. 

In cases where cardiac weakness has been a feature before 
convulsions set in, Digitalis and the Acetate of Potassium 
must be our chief reliance. 

Cutaneous (Edema. — This often requires no special treat- 



TREATMENT OF DROPSY. 



147 



ment, but if extensive or obstinate it may require methodical 
sweating, as by hot air baths or hot, wet packs. 

Acute dropsy may, in addition to sweating, require hydro- 
chlorate of Pilocarpine in hypodermic doses of one-sixth to 
one -third of a grain. But it should not be used if effect can 
be had from hot packs or hot air baths, as it may produce 
salivation or cause cardiac weakness. 

Long-lasting dropsy, after subsidence of other features, 
sometimes occurs and this may require Digitalis or Theobro- 
mine (diuretin or agurin). 

The fresh infusion of Digitalis may be used, one to four 
teaspoonfuls, according to age of the patient, three times 
daily ; or agurin, a combination of Acetate of Sodium and 
Theobromine, which is preferable to diuretin, may be given. 
The dose of agurin for adults is fifteen grains in capsules four 
or five times daily ; in the case of young children 2 to 5 years 
of age the dose should be two to five grains ; those 6 to 10 
may receive six to ten grains. Diuretin may be given in the 
same doses, but always dissolved in half a glass of water, and 
hot in conjunction with acids. 

In conjunction with the above a milk diet and the use of 
Epsom salt, one tablespoonful in sufficient water to dissolve it, 
one to three or occasionally four times daily. 

In some cases one drachm of cream of tartar in a pint of 
lemonade increases the urine and thus removes the dropsy. 

Care must be taken not to reduce the dropsy too suddenly 
for fear of uraemia. In acute nephritis Epsom salt sometimes 
produces vomiting and must be carefully administered. 

In cases where the oedema is so extreme as to become a 
dangerous feature the skin may be punctured with a lancet or 
drained with a small silver canula. A fine aspirator needle 
may be used and the fluid allowed to drain through a piece of 
long narrow rubber tubing. 

In some cases of extreme dyspnoea aspiration of hydro- 
thorax and paracentesis abdominis may be necessar3 r . 



148 INFLAMMATIONS OF THE KIDNEY. 

Colon flushings with rectal injections of normal salt solu- 
tions may be of service in the treatment of dropsy. 

Severe Vomiting. — Vomiting or diarrhoea should not be 
interfered with unless severe, when it may require special 
treatment. Cracked ice may be given and Apomorphine or 
Cocaine in the second to fourth decimal trituration. Drop 
doses of Creosote, Iodine tincture and Carbolic acid have been 
recommended, also dilute Hydrocyanic acid with Bismuth. 
Hypodermics of Apomorphine, one-fiftieth of a grain, are said 
to have relieved cases. Mercurius dulcis may sometimes be 
of service but may cause stomatitis. Ammonia water (U. S. 
P.) in ten or fifteen drop doses largely diluted, or dilute Hydro- 
chloric acid also well diluted, may be tried four times daily. 

As a palliative the writer has used fluid extract of Ergot, 
four drops, Chloroform, five drops, in one teaspoonful of 
water, for adults ; half this dose for children, followed by 
Jaborandi as above. These measures should be followed after 
relief by administration of Bismuth, Creosote, or Arsenite of 
Copper in the lower potencies. 

Inflammation of the Skin. — This is due to the oedema and 
is sometimes a serious feature. Cataplasms of mercuric 
chloride 1:1000 or of aluminium acetate 1:100 may be ap- 
plied. Antiphlogistine is also now extensively used in all 
such cases. 

Increased arterial tension should' be carefully attended to, 
as it may presage convulsions. The remedies are Aconite, 
Glonoin, Veratrum viride, Chloral hydrate. 

Acute Dilatation of. the Heart. — This dangerous complica- 
tion is shown by irregular halting action of the heart, fre- 
quent, thready, fluttering pulse, cold extremities and frequent 
respirations, pulmonary oedema impending : the treatment is 
digitalis tincture four or five minims every three or four 
hours for a day or two, ceasing for a day or two, and begin- 
ning again ; or digitalin T ^ w th of a grain instead ; or stroph- 
antus two to five minims of the tincture ; caffeine one or 



ACUTE NEPHRITIS OF PREGNANCY. 



149 



two grains, with one or two grains of sodium benzoate ; 
strychnine T ^th grain, or even more, snbcutaneously, hypo- 
dermics of camphor. 

For Signs of Collapse, as alarmingly irregular, rapid 
breathing and cool extremities, tincture of strophanthus as 
above. 

Pulmonary (Edema and Serous Inflammations. — These, ac- 
cording to Kent, are to be treated by colon flushing and 
rectal injection of normal salt solution. The principal 
remedies are tartar emetic and arsenicum in pulmonary 
oedema, and bryonia, cantharides, scilla, senega, and mer- 
curius cor., in serous inflammations. Inhalations of oxygen 
are sometimes serviceable if given early in these cases. Pul- 
monary oedema is a sign of cardiac weakness and not a part 
of the general oedema. 

It may require application of large mustard plasters to the 
chest, baths, and acetate of lead, together with remedies 
already mentioned, for relief of the weak heart. 

In the pneumonia of acute nephritis, therapeutic measures 
may prove futile ; inhalations of oxygen, tepid baths, shower- 
baths, and wet packs have been tried, but usually without 
success. 

Anceniia, following acute nephritis, requires ferrum as 
above, together with easily digested and nutritious food. 

Surgical Treatment. — Harrison, in grave cases, when death 
is imminent or in cases which show no tendency to recover, 
relieves renal tension, if it is present, by a longitudinal in- 
cision along the convex surface of the kidney, one or two 
inches in length, inserts a drainage tube, and packs lightly 
with iodoform gauze. 

THE ACUTE NEPHRITIS OF PREGNANCY. 



Definition. — A peculiar renal change found only in preg- 
nant women, cases of which are rare, and the nature of the 
disease disputed. 



150 INFLAMMATIONS OF THE KIDNEY. 

Occurrence. — The disease is a rare one, occurring in but 
one out of 250 to 300 cases of confinement and seven-eighths 
of the cases are said to be primiparae. Women who are 
illegitimately pregnant are said to be liable to it. 

The statistics of the Philadelphia Board of Health (1868- 
1873) show the occurrence of eclampsia once in every 170 
labors. 

According to a writer in the Medical Times it seems that 
the negress is liable to eclampsia, and it appears to be becom- 
ing more frequent. It occurs before labor in the latter months 
of gestation. In ten years, from 1883 to 1893 (exclusive), 11,- 
074 pregnancies (colored), deaths from eclampsia, 5 [ ; 6,054 
pregnancies (white), 19 deaths. Lusk says it is reasonable to 
estimate that for every death there are two recoveries, and 
under this ruling we would have 151 cases in the 11,074 col- 
ored, and 9.4 cases per 1,000 white, which is more frequent 
than Galaban and Kleinwacher estimate for Europe (1:5000), 
and larger than Parvin's (1:3000) for this country. Accord- 
ing to the Traube-Posenstein theory, " ahydremic condition of 
the blood " might be advanced, for the negro is becoming 
poorer each day, and this poverty means anaemia. 

Etiological Theories. — Various theories have been advanced 
to explain the production of this disease; the principal ones 
are as follows : (a) That it is due to increased abdominal and 
pelvic pressure exerted especially upon the renal veins, upon 
the ureters, or upon the cceliac ganglion, thereby causing a 
reflex contraction of the renal arteries, and a consequent 
anaemia of the kidneys, (b) The parasitic theory, that it is 
due to bacterial infection, (c) The auto-intoxication theory > 
according to which the renal lesion is due to the elimination 
of excessive amounts of waste products coming from the 
maternal and the foetal organisms. 

In spite of the modern tendency to believe in the theory of 
auto-intoxication, in which belief the writer joined for some 
years, it is by no means certain that this theory will account 



CLINICAL FEATURES OF NEPHRITIS OF PREGNANCY. 151 



for all the cases. The pressure theory still seems to hold 
good in certain cases. Modern treatment is based very largely 
on the theory of toxaemia, and most vigorous measures are 
resorted to in order to rid the blood of these substances. 

Nevertheless Achard and Castaigne have shown that an 
eclamptic may eliminate methylene blue normally, while a 
case which eliminates the blue badly may present no evi- 
dences of eclampsia. 

Pathologic Anatomy. — The kidneys are somewhat en- 
larged, pale and of a greenish-yellow color. 

Pathologic Histology. — The principal changes occur in the 
epithelium of the glomeruli and the convoluted tubules, fatty 
degeneration, cloudy swelling, and in severe cases extensive 
necrosis are found. The last is usually not diffuse, but local- 
ized in the cortex in irregular areas. Fat embolism may 
occur in the capillaries of the glomerulus. 

Predisposition. — In the author's experience women with 
history of convulsions during previous confinements, and 
primiparse of neurotic. family history are particularly liable to 
danger. 

Ivusk holds that when the disease occurs only in the later 
months, disappearing after labor even if eclampsia occur, it is 
not likely to return in subsequent pregnancies. 

Clinical Features. — These are principally scanty urine, in- 
tense albuminuria and convulsions. Before these features are 
noticed there are usually others. 

The disease probably begins early in pregnancy, manifest- 
ing itself then by the presence of a small amount of albumin 
and perhaps a few casts, but the latter may be absent. In the 
later months (seventh or eighth usually) three characteristic 
symptoms may appear before convulsions. 

They are headache, epigastric distress, and disturba?ices of 
vision. The headache may be very severe and is often ex- 
tremely so, but frequently it amounts to only a feeling of 
fullness and a moderate pain either frontal or temporal. The 



152 INFLAMMATIONS OF THE KIDNEY. 

epigastric symptom may amount to almost a crisis, so that it 
sometimes seems as if the stomach were eliminating some 
poison. Thus, one of Seabury Jones's patients who had con- 
vulsions after her second confinement suffered only from the 
former symptom in her first, but to such a degree that for 
several days no food at all could be administered. The sen- 
sation is at times one of most intense burning. The eye 
symptoms may amount only to a dimness or haziness of 
vision, or to complete loss of sight, or only to. flashes of light. 

CEdema is also a clinical feature. It is most marked in 
the lower extremities, but appears also in the face and upper 
extremities. 

Cases occur, however, in which eclampsia takes place before 
oedema or other features are noticeable, hence the importance 
of careful study of the urine. 

Frequency of micturition is often noticed. Insomnia in a 
a pregnant woman is always, according to Dr. C. T. Hood, to 
be regarded as a symptom suggestive of eclampsia. There is 
often nausea and even vomiting. It must be remembered 
that albuminuria may occur in from three to five per cent, of 
all pregnant women and not be followed by eclampsia. 

In rare cases severe symptoms occur soon after conception, 
such as vomiting, headache, etc., and abortion may occur 
spontaneously. If it does not, the patient grows worse and 
the urine becomes very scanty ; unless abortion is produced 
there is practically no treatment of service. 

[Some writers claim that there seems to be no relation be- 
tween eclampsia and renal change, the former taking place 
without any signs of renal lesion and followed by albuminuria 
as if the latter were caused by the eclampsia. Malaise and 
headache, however, may precede the convulsions. Cazeaux 
claims in opposition to this that it has never been conclu- 
sively proven that eclampsia has occurred in a case where al- 
bumin has been absent from the urine continuously for a con- 
siderable length of time preceding such accident. The 
writer's experience thus far is in accord with Cazeaux.] 



CLINICAL FEATURES OF THE KIDNEV OF PREGNANCY. 153 

The urine is usually diminished in quantity, very consider- 
ably just before convulsions, is of high specific gravity, contains 
a large amount of albumin, and is remarkable for the small 
quantity or even absence of tube casts. If present, the latter 
are usually small hyaline ones. Blood is rarely present. 

The writer's experience with this class of cases is as follows : 
In the earlier months the urine is of light color, somewhat 
diminished in quantity and specific gravity. The urea is 6 or 
8 grains per fluidounce, and albumin from a trace to one or two 
per cent. bulk. A hyaline cast or two may be found at times. 
In later months the character of the urine may change gradu- 
ally or suddenly, in some cases certainly in as short a time as 
a week, how much sooner it is difficult to say. It becomes 
scanty, much darker in color, of high specific gravity, urea 
increases in grains per fluidounce possibly up to sixteen, 
and the percentage of albumin undergoes a remarkable in- 
crease until the urine is loaded with it. At this time casts 
may be absent and are always hard to find. But in a short 
time from the occurrence of the sudden change in the general 
character of the urine convulsions occur. The writer has as 
yet not seen any cases in which the convulsions were not pre- 
ceded by this change in the character of the urine, and in 
several cases has been able to predict eclampsia twenty-four 
to forty-eight hours before it occurred. Careful distinction 
must be made, however, between the nephritis of pregnancy 
and pregnancy occurring in nephritic women. In the latter 
class of cases the writer has seen thus far but one case of con- 
vulsions, that of a woman who died from convulsions a few 
months after confinement, although she recovered from con- 
vulsions at the time of confinement. 

In the acute nephritis of pregnancy too much reliance must 
not be placed on the absence of casts. In one of the most 
rapidly fatal cases the writer has seen only one or two small 
hyaline casts could be found in the urine two days before 
death. Dr. H. M. Bascom, of Ottawa, reports ten cases, one 



154 INFLAMMATIONS OF THE KIDNEY. 

occurring early, the rest later during pregnancy. In none of 
these cases were casts found. Nine had eclampsia. Seven 
were fatal. 

Onset of Eclampsia. — About one-half of the cases of puer- 
peral eclampsia occur during labor, in the rest it occurs either 
before or after delivery. It may take place as early as the 
third month of gestation. , 

Symptoms of approaching convulsions : Rolling of the eyes, 
spasmodic twitching of the face ; as the convulsion proceeds 
the eyes turn back, . the tongue may or may not protrude ; 
respiration is interfered with, and the woman's face becomes 
turgid with blood. 

Eclampsia may begin either with mild prodromal symp- 
toms or suddenly with violent general convulsions, during 
which the child is born. A more or less persistent coma 
follows the convulsions. 

The Condition During Eclampsia. — Eclampsia usually 
begins with a short tonic stage, during which the whole body 
is generally in a position of extension in opisthotonos, follow- 
ing which there are vigorous clonic contractions in the face 
and extremities. The face becomes cyanotic, there is bloody 
froth on the mouth, the pupils are usually dilated and almost 
without reaction, the respirations are accelerated, at times 
intermittent from spasm of the respiratory muscles ; the pulse 
is small and accelerated, scarcely felt in the radial artery, and 
the temperature is sometimes elevated. 

In some cases the spasm begins with short, jerky contrac- 
tions in one extremity, as in an arm, and then invades the 
muscles, face and legs. It may happen that one-half of the 
body is more affected in the attacks than the other. The 
spasms usually cease in a few minutes, and are followed by 
deep coma and stertor lasting several hours or more. The 
spasms are likely to be repeated. As many as twenty may 
take place in the twenty-four hours, during the whole of 
which there may be complete loss of consciousness. Severe 



CAUSES OF DEATH IN THE NEPHRITIS OF PREGNANCY. 155 

and fully developed epileptiform attacks may alternate with 
slighter convulsions. After recovery there is amaurosis for a 
day or two. 

Duration. — In favorable cases there is rapid recovery after 
the birth of the child. Chronic nephritis following the dis- 
order is rare, but a slight albuminuria may persist for months. 

Causes of Death. — The patient may die from exhaustion, 
caused by the rapidity with which the convulsions come on. 
In the violent form she may die from apoplexy, caused by 
pressure upon the jugular vein ; she may die from asphyxia, 
the result of spasm of the glottis ; pulmonary and cardiac 
serous effusion; effusion upon the brain, coma, cerebral conges- 
tion ; spasm of the heart ; of the last they die instantaneously. 

Children die from violent pressure exerted by the womb 
and abdominal muscles, or they may die from toxaemia. 

The mortality is 30 per cent, in the mother and 50 per 
cent, in the child. 

Convulsions Not Uraemic. — These may be due to the follow- 
ing causes : 

A rigid, contracted cervix uteri ; small pelvis through 
which the child makes slow progress under heavy pressure ; 
severe, prolonged, ineffective pains, and the unyielding 
perineum ; these are frequent causes of convulsions of the less 
serious kind. 

A woman may have hysterical fits in childbirth ; she may 
have epilepsy. In rare cases alcoholic poisoning has produced 
convulsions. {American Practitioner.} 



TREATMENT OF THE NEPHRITIS OF PREGNANCY. 

Wright holds that the best diet is the following : 
Milk, buttermilk, koumiss, as much as the patients care to 
drink, no more ; plain water in abundance ; tea once a day, 
if desired ; cocoa, lemonade, mineral waters, etc.; stale bread 
and butter ; dry or cold toast and butter ; rice, tapioca, arrow- 
root ; fish without rich gravy ; limited amount of white meat 



156 INFLAMMATIONS OF THE KIDNEY. 

and raw oysters ; limited amount of salt ; vegetables of all 
sorts, restricting the supply of potatoes, and encouraging the 
use of greens, such as lettuce, spinach, water-cress, etc.; ripe 
fruits, such as oranges, bananas and grapes; other fruits 
cooked, such as apples, pears and peaches ; mineral waters, 
especially Hunyadi Janos, or a mixture of Friedrichshall and 
Carlsbad ; milk diluted with such waters as so-called soda, 
water or Apollinaris or Sprudel or Vichy. Patients are not 
allowed to take both milk and fish or meat at the same meal. 
In a limited number of cases, eggs, beef, mutton, and bacon 
are allowed ; but where the poison appears to injure the kid- 
neys, especially with profuse albuminuria, prohibit meats of 
all sorts, eggs, cheese and oysters, and put the patient on 
a diet largely composed of diluted milk and vegetables. 

This diet of Wright's is based on the toxsemic theory that 
the liver and intestines are at fault. 

When the urine is scanty the writer suggests the use of 
White Rock lithia water as a beverage. 

Milk diet for a long period is not desirable, and in the case 
of plethoric women not allowable. 

When convulsions are impending it is customary to put the 
patient on a rigid milk diet ; woollens are worn next to the 
skin, and a frequent warm bath is given at a temperature of 
from ioo° to 105 ° F., for three to ten minutes, followed by 
brisk rubbing. In some cases where the skin is inactive hot 
packs are better than hot tub or vapor baths, and, according 
to Powelson, safer. The bowels should be caused to move 
freely and the patient should drink freely of water. 

Preventive Treatment. — The method of Dr. Walter Wes- 
selhceft is as follows : 

The patient, wholly nude, is wrapped in a sheet which has 
been wrung out, not too dry, in tepid water. Over this a 
blanket is wrapped, the arms being kept inside, yet with a 
care not to impede respiration too much. A coverlet is then 
thrown over the patient, and she is left for about three hours 



TREATMENT OF THE NEPHRITIS OF PREGNANCY. 157 



thus, at the same time giving her plenty of carbonated 
beverages and milk. This measure is repeated twice a day. 

Ahlfeld, of Marburg, who has lately been using this 
method, reports that out of thirty-six patients, of which 
twenty-three were primiparse, with oedema and albuminuria 
more or less pronounced, where this treatment was employed, 
none had eclampsia. Besides, he had one patient who, after 
two successive miscarriages with albuminuric retinitis during 
her first two pregnancies, was able to go on to full term dur- 
ing the third with the help of these wet packs. 

Symptomatic Treatment. — Inasmuch as the pathology of 
this disorder is practically unknown, symptomatic treatment 
assumes importance. 

Aconite. — Useful in the premonitory symptoms of eclampsia 
in plethoric women, especially those who are primiparae. 
Symptoms as in acute nephritis. 

Argentum nitricum. — Constant fever and expectation of 
the approaching spasm. 

Exceeding restlessness, exceedingly violent spasms. 

Arnica. — Full, strong pulse in premonitory stage ; blood 
rushes to the head but body remains cool or of normal tem- 
perature. 

Belladonna. — When the spasms are fully developed, eyes 
red, congested and stare rigidly. There may be paralysis of 
the right side of the tongue and difficult deglutition ; bloody 
froth in the mouth and on the lips. 

Arsenite of Copper. — Useful in convulsions occurring in a 
woman with chronic nephritis, and whose heart is affected by 
the disease. The urine has an odor of garlic. The writer 
believes that gastro-intestinal symptoms preceding convul- 
sions call for this remedy. 

Gelsemium. — Symptoms simulate incipient typhoid. The 
head feels very large, the patient is irritable, sensitive and in 
nervous dread of approach of labor. 

Helonias. — Drowsiness and marked weakness, with ten- 
dency to colic, which passes away during employment. 



158 INFLAMMATIONS OF THE KIDNEY. 

Hyoscyamus. — Bluish color of trie face, twitching and sub- 
sultus tendinum marked with almost constant delirium. 

Mercurius cor. — The urine is scanty, with frequency of 
urination at night, and yellowish tint to the skin. 

Opitim. — In convulsions due to suppression of labor pains ; 
constant stertorous respiration, both on inhalation and exhala^ 
tion, with stupor, half closed eyes, etc. 

Stramonium. — Much fear and shrinking, followed by 
spasms. 

Terebinth. — In rare cases when the urine contains blood. 

Uranium nitrate. — Rising at night to urinate, and passage 
of hyper-acid urine ; in ill-tempered, despondent patients ; ab- 
normal mammary development and hyper-secretion of milk. 

Mercurius cor. and Helonias are used in diametrically oppo- 
site conditions ; the former when the urine is scanty, the 
latter when clear, light-colored and profuse. Apis has scanty 
urine like Mercurius, but oedema of the face and extremities 
is marked. Arsenicum when numbness, prostration, anaemia 
and dropsy are features. 

Glonoin is suited to congestive headaches, pulsations, quick 
throbbing, frequent desire at night to urinate, and rush of 
blood to the head. The writer, however, finds that Aconite 
is more reliable for precisely these symptoms than Glonoin. 
Apocynum is indicated in dropsical conditions, slowly-acting 
kidneys, with weakness, depression, drowsiness and labored 
action of the heart. If too large doses irritate the stomach, 
administer liquid pepsin after it, as in case of diuretin. 
Lachesis is indicated in dropsical conditions associated with 
albuminuria, where cedematous tissues are dark ; when the 
urine is dark and albuminous and the symptoms are worse 
after sleeping. 

Jaborandi, or its alkaloid, Pilocarpine, is given as a routine 
measure in doses of \ to \ of a grain, hypodermically, once 
weekly after albumin appears until no longer necessary. It 
should not be given unless respiration and heart are normal. 



THERAPEUTIC MEASURES IN THE KIDNEY OF PREGNANCY. 159 

Uranium nitrate is said to be valuable the more closely trie 
symptoms resemble diabetes mellitus. (See above.) 

Chloral hydrate may be used in routine treatment ; fifteen 
grains are dissolved in water and added to six fluidounces of 
simple syrup ; a teaspoonful is given every four hours when 
uraemia is threatening, as suggested by Dr. Kinyon, af Ann 
Arbor. 

Palliative Treatment. — Diastase, lactopeptine, caroid and 
similar agents may be of service in the gastric disturbances. 

Potassium or Lithium citrate is serviceable when the urine 
is scanty. Hood uses the following powder three times 
daily : 

& Apis, first decimal trit, gr. x. 

Lithium citrate, ' .»gr I. 

Senna. — According to Hood this is the best thing for the 
sluggish bowels of a pregnant woman. Take one ounce of 
fresh senna leaves and one-half ounce of fennel seed with one- 
fourth ounce of solid extract of licorice. Steep these over a 
slow fire for several hours, making of this twelve to sixteen 
ounces of liquid after it is strained. Add four ounces of 
sugar. Of this she should take one to three teaspoonfuls at 
night. 

Arsenite of Copper may be given the patient to prevent the 
return of convulsions. Use the second decimal trituration. 

Digitalis. — This remedy may be given internally or in the 
form of foxglove poultices, applied to the lumbar region, 
when the urine is scanty, to promote diuresis. 

Veratrum viride. — Cases in which there is a full bounding 
pulse, suffused face, convulsions, patient returning to con- 
sciousness between convulsions. It reduces the temperature, 
relaxes the cervix, and causes prompt diaphoresis and diuresis. 
Dose, 5 to 10 minims of Norwood's tincture every 20 or 30 
minutes until the pulse falls to sixty or below. 

SPECIAL THERAPEUTIC MEASURES. 
When uraemia threatens, the patient should be caused to 



160 INFLAMMATIONS OF THE KIDNEY. 

have ten or twelve watery movements of the bowels for a day 
or two and subsequently four movements daily every day by 
means of administration of Epsom salt. Not less than two 
evacuations a day should be allowed until after labor. 

During convulsions Hood gives Norwood's tincture of Vera- 
trum viride, if the pulse is over 80, in doses of 10 to 15 
minims hypodermically. The colon and rectum are emptied 
and the colon filled with normal salt solution ; if it is not 
retained, intravenous transfusion is performed. If the pulse 
does not fall to 80 in thirty minutes the dose of Veratrum is 
repeated, and again in an hour. A pint or two of blood is 
withdrawn and one-third more salt solution than blood in- 
jected. Chloroform by inhalation is given until the patient 
is able to swallow, when four grains of Calomel and five of 
Sodium Bicarbonate are given, and the same repeated in two 
hours ; in four hours a saline cathartic is given. If sweating 
is necessary, the hot pack is preferable to the hot tub bath. 

If induction of labor is necessary, the patient should be 
thoroughly purged by the use of Epsom salt, and sweated by 
means of the hot pack before the operation is performed. 

For weakness of the pulse Powelson advises oxygen gas, 
whisky and Digitalis. 

For the distention of the bowels after recovery from convul- 
sions Epsom salt and glycerine enemas. 

For coma and suppression of urine after convulsions Arse- 
nite of Copper second decimal trituration, Digitalis tincture 
and foxglove poultices over the lumbar region. 



CHAPTER VIII. 



CHRONIC NEPHRITIS. 



The principal characteristic of chronic nephritis pathologi- 
cally is a productive inflammation of the interstitial tisstie or 
stroma. For this reason the term parenchymatous or tubal 
is inapplicable to chronic nephritis ; while epithelial changes 
may in some cases overshadow the interstitial inflammation, 
nevertheless the latter always exists, hence the necessity for 
use of the term diffuse. Clinically speaking, cases of nephritis 
which last six months or more are assumed to be chronic 
rather than acute. On the other hand, and in the majority of 
cases of some chronic forms, the disease is insidiously chronic 
from the onset without ever having been acute. 

Pathologically, it is impossible to draw a sharp line between 
acute and chronic nephritis, since the alterations in the latter 
are only an intensification of the processes characteristic of the 
former. (Riesman.) 

We classify chronic nephritis chiefly according as the kid- 
ney is softer or harder than normal. That type in which 
the consistence of the kidney is decreased receives the 
name of chronic diffuse nephritis without induration ; that in 
which the consistence is increased is given the name of 
chronic diffuse nephritis with induration. This classification 
is, on the whole, more satisfactory than one based on the size 
of the kidney, for the reason that kidneys larger than normal 
may be totally different in their pathological changes. 



CHRONIC DIFFUSE NEPHRITIS WITHOUT INDURATION. 
(CHRONIC NON-INDURATIVE NEPHRITIS.) 

Definition. — k. form of chronic diffuse nephritis in which 
the new cells of the stroma do not proceed to form mature 
ii 



162 CHRONIC NEPHRITIS. 

connective tissue, hence absence of scar-tissue, of contraction, 
and of hardening or induration, except in advanced cases, 
where mote or less fibrous tissue fotmation may be found in 
limited areas. 

Synonyms. — Bright's disease, second stage ; chronic 
croupous nephritis ; chronic tubular nephritis ; large white 
kidney ; fatty kidney ; chronic parenchymatous nephritis. 

Note. — This is the disease discovered by Dr. Bright , hence 
sometimes called " the Bright's disease of Bright." 

Etiology. — The causes are as follows : 

i. Most commonly it arises obscurely and insidiously from 
unknown causes ; possibly due to elimination of micro-organ- 
isms in the course of acute infectious disorders, especially the 
pyogenic cocci and the bacillus coli communis. 

Among the supposed causes are the following : 

Malaria, syphilis, exposure to cold and wet, alcoholism and 
chronic heart diseases. 

Diseases of the lower urinary tract, especially calculous dis- 
orders, purulent cystitis, stricture of the urethra and prosta- 
titis. It may accompany malignant neoplasms, and the latter 
escape recognition in consequence. 

It occurs in the course of chronic anaemia ; especially in 
that due to phthisis, cancer, gastric ulcer and in pernicious 
anaemia. 

It is associated with amyloid degeneration of various organs, 
and perhaps is due to the causes of amyloid disease. (See 
Amyloid Kidney.) 

2. In rare cases it is the result of acute nephritis, especially 
(a) post-scarlatinal, (b) idiopathic, (c) that of pregnancy, (d) 
that of malaria, and (e) that of exposure to cold. 

3. Metabolic poisons elaborated in the digestive tract or in 
the interior of organs or muscles may be presumed to be a 
factor in the causation. 

It is said that irritation of the renal epithelium by excre- 
tion of tubercular toxins may produce this form of nephritis. 



PATHOLOGIC ANATOMY OF LARGE WHITE KIDNEY. 163 

Occurrence. — Most often in men between twenty and forty. 
The writer finds it especially common in men who have led 
what is known as a " hard life," that of poverty, exposure and 
drink. 

It may, however, occur in children and women. 

In the writer's experience several cases of it have occurred 
in anaemic young women. 

According to Edebohls it may be unilateral in one-half the 
cases. 

Pathologic Anatomy. — The Kidneys. — Large, flaccid, 
doughy. As a rule, larger than normal, sometimes double 
normal in size. The larger the softer, and in general usually 
softer than normal. The color, yellow or red, according to 
the amount of fat or of blood. Pale color is common. 

The Capsule. — Taut but easily stripped. 

The Surface. — Smooth, grayish-yellow or yellow, sometimes 
mottled with white and deep yellow patches. Has an oily 
feel, and oil drops are seen on the section-knife. 

The Superficial Veins. — Conspicuous. 

Section. — The cortex wider than normal, of yellowish or 
mottled color, the medullary rays of grayish translucent 
appearance ; the pyramids usually darker than cortex, some- 
times uniformly yellow with it. 

There are three kinds of kidneys according to color, the 
large red, the large white or yellow, and the large mottled. 

When the yellow color predominates, the kidney is known 
as the large white or yellow kidney (Fig. 14), synonymous with 
what has been called chronic parenchymatous nephritis. The 
color where yellow sometimes resembles that of butter. The 
pale color is due to fatty changes and to anaemia. 

In case of necrosis of the entire kidney the latter diminishes 
in size and becomes softer than normal, and of a dirty-yellow 
color. 

Congestion and haemorrhages may modify the appearance 
of the kidney to such an extent that its size is merely normal 



164 CHRONIC NEPHRITIS. 

or only slightly larger and its consistence even somewhat in- 
creased. On the surface, in such cases, grayish or yellowish 
areas alternate with reddish ones, producing a variegated ap- 
pearance. This condition is known as chronic hcemo7 r rhagic 
nephritis or the large mottled kidney. 




Fig. 14. I^arge white kidney showing commencing retrogression. — (Ralfe). 

On section the cortex is found widened and marked with 
reddish striae or reddish patches of haemorrhage. In this 
kidney the capsule may be adherent in places. 

Pathologic Histology. — The principal characteristic is fatty 
change in the epithelium. Changes in the glomeruli are 



CLINICAL FEATURES. 



165 



always present and are both degenerative and proliferative. 
In a large number of cases the glomerular changes are far 
more marked than the tubular, hence the term chronic 
glomerulonephritis. 

The degenerative changes may cause almost complete dis- 
integration of the affected glomeruli. 

The proliferative changes may result in highly cellular 
glomeruli. 

Change in the tubules is common and affects especially the 
epithelium of the convoluted tubules with fatty degeneration ; 
in advanced cases the epithelium of the straight tubules may 
also be involved. Usually not all the cortical tubules are af- 
fected, the degeneration tending to be focal in character. 

Changes in the interstitial tissue are ordinarily not very 
marked. They consist in oedema and small foci of round-cell 
infiltration about the glomeruli and veins. 

In the hcemorrhagic cases we find the following : (a) In the 
glomeruli an abundant exudate of blood into the capsular 
spaces ; (b) in the tubules abundance of red blood corpuscles, 
which may be distinct and separate or fused into homogeneous 
colloid masses, with altered blood pigment in the epithelial 
cells ; (c) in the interstitial tissue presence of altered blood 
pigment and fat granules ; there is a more marked tendency 
toward production of new fibrous tissue. 

In these cases fatty changes are less pronounced. 

Onset. — The patient at first is pale and out-of-sorts, loses 
his appetite, and may become easily nauseated, have a gastro- 
intestinal crisis or headache. CEdema then appears, and is 
usually the first thing to attract attention to the kidneys. 

Diagnosis. — Dropsy, anaemia, together with albuminous 
urine containing abundant sediment, are the cardinal features. 
There may also be headache, nausea and vomiting. 

Clinical Features. — Dropsy. — First puffiness of the eyelids 
in the morning, swelling of ankles and feet toward night ; 
later progressive, obstinate and general throughout the whole 



166 CHRONIC NEPHRITIS. 

subcutaneous tissue; eventually extreme, and ultimately in- 
volving serous cavities, lungs and brain. 

It may persist even when violent diarrhoea is present, or 
when there is an abundant flow of urine. In rare cases there 
is no oedema but periodic renal haemorrhages {chronic hemor- 
rhagic nephritis without dropsy). 

The more severe and comparatively acute the case the 
greater the dropsy. 

Dropsy is found in the beginning of the cases ; its course 
may be either slow or rapid until it is of great intensity, and 
it may persist for months. 

In some cases oedema of the glottis is found. 

Ancemia. — Face pale, puffy ; mucous surfaces pale ; ex- 
tremities and body dough-like. In very chronic cases less 
anaemia. 

Debility. — Progressive. Patient feeble, helpless, finally 
bed-ridden. 

Emaciation. — Also progressive, but masked by dropsy. 

Digestive Disturbances. — In the beginning loss of appetite 
and morning nausea ; later vomiting before breakfast, diar- 
rhoea. Diarrhoea is, however, not so prominent as in amyloid 
kidney. Loss of appetite is very common. Constipation is 
more common than diarrhoea. In severe cases in the last 
stage there may be dysentery and intestinal ulceration. 

Condition of the Heart. — There is often hypertrophy of the 
left ventricle with or without dilatation, and in some cases of 
the right. Dropsy may interfere with the examination of the 
heart, but the abnormally tense pulse, accentuation of the 
aortic second sound and displacement of the apex outward, or 
at least increased strength of beat will be noticed. Endocar- 
ditis and pericarditis are rare. 

The Pulse. — The tension increases, and the arteries gradu- 
ally become stiff, or the left ventricle becomes hypertrophied. 

Urcsmic symptoms in the disease are more commonly those 
of chronic rather than of acute uraemia, namely, stupor, slight 



CLINICAL FEATURES. 167 

vertigo, expression of suffering, headache, cutaneous pruritus 
frequent vomiting before or after meals, or when fasting, 
serious dyspepsia, diarrhoea, and especially asthmatic troubles. 

Convulsions have been known to follow disappearance of 
dropsy after hot bath. 

According to Southey, out of 106 cases with dropsy only 
thirty-eight had uraemia, or 35 per cent. Furbringer's experi- 
ence is that only 17 per cent, had uraemia. 

Uraemia may occur at any time, but not usually in full 
development, and is somewhat rarer than in chronic intersti- 
tial nephritis. 

Miscellaneous. — Headache and wakefulness ; vaso-motor 
affections resulting in hyperaesthesia and paraesthesia ("dead 
finger," itching, burning, etc.) may be the earliest symptoms 
of the disease. 

Habitual abortion (premature loosening of placenta, forma- 
tion of white nodules) has been observed. 

I he ear is frequently affected in this disorder — otitis in- 
terna, pains and noises without evident cause, sudden deafness 
from labyrinthine affection, remarkable changes in the hear- 
ing, etc., are noticed. 

In rare cases the symptoms are those of cholera nostra, or 
genuine dysentery, masking other symptoms, save dropsy and 
albuminuria. 

Abortive forms may exist without symptoms other than 
granular casts and renal epithelia in the urine ; or there may 
be the usual dropsy, anaemia, chronic dyspepsia, etc. The 
patients are usually alcoholics, and the disorders may remain 
stationary or even be partially cured (slight nephritis with 
circumscribed lesions). 

Striking remissions and intermissions are frequently seen, 
with disappearance for a time of albumin, casts and dropsy, 
and increase of strength. 

As to inflammations of serous membranes, pleurisy is most 
common, peritonitis next and pericarditis third. 



168 CHRONIC NEPHRITIS. 

Affections of the liver and spleen occur, as hepatitis, nutmeg 
liver, lipomatosis hepatis, acute and chronic tumors of the 
spleen. 

Violeiit renal hemorrhages should not be held to indicate 
an acute rather than a chronic lesion. 

Retinitis occurs in some cases. 

Forms of bronchitis and pneumonia occur as in the acute 
nephritis. Recurring attacks of bronchitis are of frequent oc- 
currence. 

In all cases of nephritis the physician should be on the alert 
for signs of pericarditis. 

Gatchell says : " One of the signs to be found at this early 
period is in the third left intercostal space. Sometimes, for 
one or two days preceding the appearance of the friction- 
sound, there can be detected in this space diminished respira- 
tory action. It later extends to the second interspace. An- 
other early sign is a peculiar loud metallic character of the 
pulmonary second-sound. 

" The two signs described belong to the premonitory stage of 
the disease. After the inflammation has become established 
other signs, some of which are of a more positive character, 
follow. The to-and-fro friction sound, when detected, is of 
diagnostic importance. Sometimes it is transient, and so may 
be lost. When there is effusion, even though it may be 
moderate in amount, the most important sign is the one to 
which attention was called by Rotch. This is the appearance 
of dullness in the cardio-hepatic angle, which is in the fifth 
right interspace, adjacent to the edge of the sternum. Nor- 
mally, there is dullness at the cardio-hepatic angle, due to 
the deep dullness of the liver. But when there is fluid in the 
lower right sulcus of the pericardial sac the percussion note 
in this space is of much higher pitch, amounting even to ab- 
solute flatness. This is an important diagnostic sign when 
there is small amount of effusion. 

" Other important diagnostic signs are the detection of the 



THE URINE. 169 

apex-beat inside the left line of dullness, and also a full, 
strong pulse with enlarged area of precordial dullness, cardiac 
hypertrophy being excluded. 

" There is another sign concerning which our views must be 
altered. Tradition says that with copious effusion the heart 
may be displaced upward and to the left so that the apex-beat 
may give evidence of being as high as the third interspace. 
But tradition is wrong. The pulsations occurring in this 
space are caused by the action of the right ventricle, and not 
by the apex." 

The Urine. — Quantity. — About half normal, or less than 
two pints, with marked fluctuations. Night urine, on 
average, equals, or more often exceeds, day. 

Specific Gravity. — Usually below 1.020 ; sometimes higher. 

Appearance. — Opaque, hazy, dirty. 

Color. — Runs from pale to dark-red, according to quantity 
of urine. 

Reaction. — Acid. 

Albumin. — Abundant. Seldom less than 3 to 5 in Esbach 
tube, and often enormous, one to five per cent, by weight, 50 
per cent, or much more by bulk, practically filling the whole 
tube when coagulated. Percentage increases with the specific 
gravity. 

Urea. — Diminished, usually both relatively and absolutely. 
Seldom normal or above normal per 24 hours, except when 
dropsy subsides. 

Chlorides. — Diminished. 

Phosphates. — Usually diminished in ratio to urea. 

Sediment. — Milky, abundant ; remarkable for variety and 
number of constituents ; all sorts of casts, various in length 
and breadth ; broad hyaline, dark granular and fatty the char- 
acteristic casts. Granular masses numerous ; numerous pus 
corpuscles, disorganized renal epithelia, fat drops, fat crystals? 
small shreds of connective tissue. Few blood corpuscles ex- 
cept during acute recurrences, or in hsemorrhagic cases in 



170 CHRONIC NEPHRITIS. 

which blood coloring matter and corpuscles are both pres- 
ent. It is of importance to notice whether blood is present, 
visible to the naked eye, in order to distinguish the chronic 
haemorrhagic cases. 

A large amount of liquid ingested may not greatly increase 
the quantity of urine. 

In extreme cases, when the urine is less than ten fluid- 
ounces for twenty-four hours, an enormous quantity of albu- 
men (nearly 5 per cent, by weight) and high specific gravity 
— 1.045 t° 1-050 — have been noted. 

The writer has frequently found the total urea for twenty- 
four hours but little decreased. Before death, however, in 
the same cases, a marked decrease took place. 

Duration. — Subacute cases last from three to six months ; 
the very chronic cases may last two or three years by transi- 
tion into secondary chronic interstitial nephritis. 

Cases which begin more acutely last about three months ; 
those which begin gradually, much longer — a year or more. 

In severe cases death from dropsy or uraemia takes place in 
from three months to a year. Dangerously severe attacks of 
acute nephritis may occur in the course of the disease and 
render the prognosis unfavorable. 

Prognosis. — Recovery is possible when the disease is 
limited to a portion of the kidney, and this explains the unex- 
pected recoveries which we often see. Long continued dropsy 
with scanty urine are unfavorable signs. Sudden increase in 
oedema or onset of severe uraemia unfavorable. Milder forms 
may terminate favorably for the time, but develop into severe 
nephritis frequently. 

Incomplete recovery may take place, i. e., a long pause, 
with almost entire disappearance of albumin and dropsy. 
Large quantities of albumin, prolonged decrease in the twenty- 
four hours' quantity of urine, and increase in the pus corpus- 
cles of the sediment are said to be unfavorable signs, but re- 
missions may take place even under such circumstances. 



CHRONIC HEMORRHAGIC NEPHRITIS WITHOUT 03DEMA. 171 

Most writers hold that casts, however numerous, do not have 
much influence on the prognosis, yet the author has seldom 
observed recovery in cases where the long, dark, granular 
casts are numerous. While complete cures are exceptional, 
even the most serious cases can sometimes be cured, especially 
if of malarial or syphilitic origin. 

In a large number of cases observed by the writer during 
seven years, 42 per cent, were dead at the end of that time. 

McNutt says as many as 50 per cent, of the cases recover. 

If the disease lasts beyond a year, the prognosis becomes, 
according to Purdy, increasingly gloomy. The longer after 
six months it lasts the less likely is recovery. 

The disease frequently spares weak patients but carries off 
vigorous ones. 

Fiirbringer mentions the case of a patient who had re- 
mained weeks in ursemic coma, and from whom over fifty 
quarts of fluid had been drawn by puncture, who nevertheless 
recovered sufficiently to go about the hospital gardens, the 
kidneys having gone on to the stage of contraction. 

Cases due to malaria, syphilis, or surgical processes may be 
treated successfully. 

After the transition to secondary chronic interstitial neph- 
ritis recovery may be simulated for a time, but eventually the 
patient manifests ursemic phenomena. 

Cases which have lasted a year or more almost never re- 
cover. (Anders.) 

Dangers. — Emaciation and exhaustion from dropsy and 
hydrgemic conditions of the blood. CEdema of the lungs or 
larynx. Intercurrent acute inflammations of the lungs or 
serous cavities, as pleurisy, pneumonia ; or erysipelas. 

In some cases uraemia becomes a dangerous feature, but not 
so commonly as in other forms of chronic nephritis. 

CHRONIC HEMORRHAGIC NEPHRITIS WITHOUT CEDEMA. 

This disorder is somewhat rare, but should be carefully 
distinguished. There is usually history of some suppurative 



172 CHRONIC NEPHRITIS. 

process, septic infection or toxaemia. The clinical features 
are confined almost wholly to the urine. Uraemia is rare, 
and there is no cardiac hypertrophy. The writer has noticed, 
however, in one case marked accentuation of the aortic second- 
sound. 

The urine contains always more or less blood, a little albu- 
min and hyaline casts, the latter frequently containing red 
blood corpuscles or haematoidin granules. The course is 
slow and recovery uncertain. It has been noticed that ap- 
parent recovery is usually followed by a sudden haemorrhage. 
The termination is probably secondary chronic interstitial 
nephritis. 

In one case of this kind which the writer now has under 
treatment the patient is to all appearances well and feels well. 
The urine contained at first a few per cent, by bulk of albu- 
min, together with red blood corpuscles and a few casts. 
Careful diet and small doses of Strychnine phosphate reduced 
the albumin to a trace, but blood corpuscles are found every 
time the urine is examined. 

Differential Diagnosis. — The different forms of chronic 
diffuse nephritis without induration should be carefully dis- 
tinguished. 

Earge motteed kidney. earge white kidney. 

History of alcoholism. 

Dropsy not of high degree; or may Dropsy marked, of high degree, 
be absent. 

Cardiac hypertrophy and retinitis. Cardiac hypertrophy very common. 

Uraemia quite frequent. Uraemia frequent. 

Urine persistently rich in red blood Urine contains but little or no 

corpuscles and casts. blood. 

Duration commonly six to eighteen Duration may be six to eighteen 

months. months, but is usually shorter. 

Chronic non-indurative nephritis is distinguished from 
acute nephritis by the age, history and duration of the case. 
In adults acute nephritis, except that of pregnancy, is rare. 
History of an acute infectious disease points to acute nephritis. 



TREATMENT OF CHRONIC NON-INDURATIVE NEPHRITIS. 173 

When the tube-casts are in the main dark granular, fatty or 
waxy the case is most likely chronic, no matter what the age 
or history is. 

Chronic non-indurative nephritis is distinguished from 
chronic (passive) hypersemia by the abundance of albumin and 
casts, and the usual absence of mitral lesions. 

Chronic non-indurative. nephritis is distinguished from 
chronic primary interstitial nephritis by the presence of 
oedema early, and by the large amount of albumin and the 
number and variety of casts. 

Chronic non-indurative nephritis is distinguished from 
amyloid kidney by the absence of history of suppurative pro- 
cesses and of enlarged liver and spleen. 

TREATMENT OF CHRONIC DIFFUSE NEPHRITIS WITHOUT 
INDURATION. 

General Treatment. — Greatest care in avoiding chilling of 
the surface. Removal from proximity to large bodies of cold 
water like the Northern oceans, seas and lakes. Continuous 
residence in warm, equable climate. When change of climate 
is not possible, heavy woolen underclothing is to be worn day 
and night. Habitual free ingestion of liquids to promote 
perspiration. 

During the winter patients should be kept in a warm, well- 
ventilated room, and in recumbent position as much as possi- 
ble. The temperature should be about 75 ° F. 

Women must stay in bed, or at least in a recumbent posi- 
tion, during the menstrual period. 

All over-exertion to be avoided. This is a relative term : 
comparatively slight exertion may be over-exertion to some 
patients. Sexual intercourse, use of alcoholic drinks, tobacco, 
etc., are in the same category. 

The writer believes that if patients would go to bed and 
stay there for a long period of time the percentage of recoveries 
would be greater. 



174 CHRONIC NEPHRITIS. 

Bathing — From ten minutes to half an hour every one 10 
three days in water, temperature of which is gradually raised 
to 105 ° F. Rubbing, massage, and wrapping in blankets after- 
wards, but excessive sweating to be avoided. Best taken at 
night. 

Robust patients may take vapor baths preferably, with 
stay, when possible, in apartments where bath is given, until 
next day ; such baths to be taken daily, or once in three or 
four days, according to strength. If uraemia threatens, twice 
daily. 

The question of bathing is an important one. Powelson 
advocates the use of the hot pack in preference to the hot tub 
bath. He mentions the case of a young girl who bore a num- 
ber of hot packs well, but immediately went into coma and 
died after being put into a hot tub bath. The writer saw a 
case in an elderly man where the hot air bath immediately 
produced unconsciousness and death on the following day. 

The writer thinks favorably of mud-baths in the treatment 
of chronic nephritis, used of course in conjunction with other 
means. The feature of the mud-bath, which commends itself, 
is the evenness of the temperature and the absence of chill. 

For residents of the Middle West the mud-baths at Kramer, 
Indiana, near Attica, on the Wabash railroad and Chicago 
and Eastern Illinois, are convenient and the hotel comfort- 
able. 

Diet in the Less Severe Cases. — The patient may take the 
following : 

1. What he does take frequently, but little at a time. 
Soups : Vegetable, sago or vermicelli. 

2. Oysters (raw t only) and fresh fish, which should not be 
fried. Shell-fish in general, if fish is not well borne. 

3. Meats : Tender beefsteak and mutton chops once a day, 
but not in very severe chronic cases. The fat portions of 
steaks and chops to be preferred. White meat of poultry. 
Chopped beef. 



DIET IN CHRONIC NON-INDURATIVE J\EPHRITIS. 175 

4. Vegetables : Green vegetables, except beans and peas ; 
vegetable salads. 

5. Farinaceous food : In general, properly-cooked farina- 
ceous foods are allowed. Well-risen bread, toasted stale bread, 
well-cooked rice, tapioca, arrowroot, etc., bread and milk. 
Battle Creek Foods. 

6. Desserts : Rice pudding, milk pudding, tapioca pudding. 
Fruits : Those which are laxative and those not too acid, as 
ripe peaches, pears and especially grapes. Iceland moss 
jelly. 

In some cases where the symptoms are not urgent, fruit, 
as, for example, an orange first at breakfast, followed by oat- 
meal and cream, are advisable. At the noon meal, tender 
steak, or chops ; at night, skim milk and "zwieback." 

7. Drinks : Distilled water, flavored with lemon juice ; 
such mineral waters as are almost free from solids. 

A small amount of light wines may sometimes be allowed 
those who are in the habit of taking alcoholic drinks. Butter- 
milk is an excellent drink for those who like it. 

Articles to be Avoided. — The patient should avoid the 
following : 

1. Overloading the stomach ; all animal soups. 

2. Cooked oysters and fried fish. 

3. Meats : All smoked and seasoned meats ; ham, tongue, 
corned beef, sausages, pork ; all hashes and stews ; turkey, 
lamb, gravies ; eggs in some cases. 

4. Vegetables : Beans and peas. 

5. Farinaceous foods : Heavy, soggy bread ; batter cakes. 

6. Dessert: Pies, cakes, ice cream. 

7. Beer, ale, porter, coffee, ice water. Hard waters not to 
be taken if purer waters can be obtained ; the solvent power 
of hard water is not as great as that of soft. 

In general it may be stated that starchy, saccharine and 
oleaginous articles of food are to be preferred to nitrogenous 
ones, and if the patient can do without meat it is advisable 



176 CHRONIC NEPHRITIS. 

for him to drop it, or, if he craves it greatly, to eat fat meat 
only. 

It must be admitted that there are some patients who do 
not do well on any one-sided diet, but for whom ordinary 
mixed diet is the best thing. Schreiber actually recommends 
that patients under ordinary mixed diet eat in addition eggs, 
either raw or boiled, and meat. Some physicians report suc- 
cess from the use of raw eggs and milk. 

Dark meats, as of wild fowl, are to be avoided, and all meat 
extracts. 

Some patients cannot eat fish but can take shell-fish in 
moderation. 

Eggs may be tolerated by some patients but not by others, 
according to the condition of the digestion. 

Diet in Severe Cases. — The writer's experience is favorable 
to adoption of the rigid milk diet for a limited period of time, 
and with careful observance of details. Milk diet has fallen 
somewhat into disrepute on account of indiscriminate and too 
prolonged usage, but if rightly administered it is exceedingly 
valuable in causing decrease of dropsy and amount of albumin 
in the urine, together with increase in the quantity of urea. 
From two to four quarts of skimmed milk and that only 
should be taken during the twenty-four hours as follows : 

The patient is to take three or four times daily, and at 
regularly observed intervals, from two to six ounces of skim- 
med milk. 

This must be taken slowly, and in small quantities, so that 
the saliva may be well mixed with it. The reaction of the 
milk to test-paper must be neutral or alkaline. 

The first week is the most difficult to get over, unless the 
patient has a strong will. 

During the second week two ordinary quarts (sixty-four 
fluidounces) may be consumed during the day. The milk 
must be drunk four times daily, 8 A. M., at noon, at 4 and 8 
P. m. The hours may be changed, but regular intervals must 
be maintained. 



NOTES ON MILK DIET. 



177 



If the patient comply with these directions he will complain 
neither of hunger nor thirst, although the first doses appear so 
very small. 

The daily quantity may be increased to eighty or more 
ounces. 

If, after having attained this quantity or more, the patient 
gets worse, diminish the amount to the quantity used the first 
week, and increase more slowly. 

Constipation at the beginning is a good sign. This may 
be remedied by warm water injections, or by the use of castor 
oil, rhubarb, addition of sugar of milk to the milk, or by tak- 
ing some bicarbonate of soda at bed time. If the constipation 
be obstinate a little coffee may be added to the morning dose 
of milk, or, towards 4 p. m., stewed prunes or a roasted apple. 

If, on the other hand, diarrhoea results, and rumbling of 
the bowels is frequent, the milk is too rich or is being taken 
in too large doses. 

Feverishness is no contra-indication to its use. If the 
patient be thirsty, he may drink Hydrox, Bethesda, Poland 
or Vichy water. If he have a strong desire for solid food at 
the end of the second or third week, he may have a little stale 
white bread or toasted bread with salt in the morning, and 
again at 4 p. m. Once a day at this time he may have some 
soup made of milk and oatmeal. 

After continuing this treatment for five or six weeks it may 
be modified by allowing the milk only thrice daily, and once 
a day steak or a chop. Raw meat digests most easily, and 
should be used in preference to the cooked when possible. 

It may be necessary to add a little salt to the milk in some 
cases, and in others to have the milk drunk when very hot. 
If the patient becomes flatulent, buttermilk is often beneficial 
in small quantities. 

Notes on Milk Diet. — 1. Exclusive milk diet must be 
abandoned when it causes too great polyuria, when symptoms 
of anaemia and exhaustion are noticed, and when the albumin 
12 



178 CHRONIC NEPHRITIS. 

is but small in amount. In such cases allow vegetables and 
farinaceous foods, as oatmeal, cracked wheat, granula, wheat- 
ena, and, if the patient still loses strength, a small amount of 
broiled or roasted meat once daily at early dinner. 

2. Milk which has been violently shaken is said to be better 
tolerated than that which is not. 

3. When the stomach is very irritable an ounce of iced 
milk may be given every half hour. 

4. When milk is not tolerated, peptonizing it sometimes 
results in toleration. 

5. In some cases malted milk is better borne than milk 
alone. 

6. Kumyss, matzoon or buttermilk may be substituted 
partly or wholly for the sweet milk, if the latter is not well 
taken. 

7. The writer seldom finds patients who are unable to take 
milk when it is mixed with French Vichy water, beginning 
with one-third milk to two-thirds Vichy, and progressing to 
two-thirds milk and one-third Vichy. 

8. In one desperate case (a boy of 8) which the author saw, 
the milk was made palatable by flavoring with vanilla extract 
and adding sugar. The patient took this with eagerness, 
though refusing other kinds of milk mixtures, and finally 
recovered. 

9. When the patient has improved, arrowroot and rice, 
together with cereal foods, fat bacon, zwieback, butter, 
mutton-broth, chicken-broth, clam-broth and oyster-broth 
may be allowed. 

10. In some cases clam-broth alone has been taken as a 
diet to the exclusion of milk, when the latter was not tol- 
erated or failed to nourish. 

There are some patients who seem to be entirely unable to 
bear the absolute milk diet and who do better on a carefully 
regulated mixed diet, avoiding the articles already mentioned. 
Whole wheat water is sometimes well tolerated by those un- 
able to take milk. 



NOTES ON MILK DIET. 179 

Robin believes that a diet may be found for a given patient 
which will cause the minimum elimination of albumin. He 
begins treatment by an absolute milk diet as follows : From 
7 o'clock in the morning to 10 at night he should take a pint 
of hot milk every three hours, in small mouthful s, taking about 
half an hour to drink this quantity ; three quarts will be in- 
gested during the day. When tolerance has been established 
the quantity should be gradually increased until four or five 
quarts are taken during the day. Under the influence of this 
diet there will be at first in nearly all instances an increase in 
the quantity of albumin for the twenty-four hours. After 
this usually transient increase, the albumin falls until it 
reaches an amount which is almost stationary. At this point 
green vegetables, cooked fruits and bread are added to the 
dietary. Finally, eggs and meat are given if the milk-vege- 
table diet does not appear to influence the quantity of albumin. 
If the amount of albumin has been tested regularly, one will 
now be enabled to find the general diet that will cause the 
least elimination of albumin. In conclusion, Robin states : 
(i) During an absolute milk diet, the milk-vegetable diet or 
the milk-animal diet there is generally less albumin than 
when the dietary does not include milk ; (2) albumin is in- 
creased when wine is substituted for milk ; (3) eggs produce 
less albumin than a meat diet ; (4) a diet of eggs and milk 
causes less albumin than absolute milk diet ; (5) among the 
meats, veal and beef agree better with albuminuric patients 
than chicken and mutton ; (6) fish always appears to increase 
the elimination of albumin ; (7) the vegetables which cause 
the least elimination of albumin are potatoes, cauliflower and 
rice ; (8) it is rare that the addition of bread to any diet will 
increase the elimination of albumin. 

The writer is thus far unable to verify Robin's conclusions 
as to beef and fish. 

Many patients are able to take matzoon or kumyss and 
grapes as a rule are well borne. 



180 CHRONIC NEPHRITIS. 

Anders advises when there is mnch dropsy a diet of dry- 
bread, crackers, zwieback, skim milk, butter milk and mat- 
zoon. 

Hirschfield allows six ounces of meat, thirteen ounces of 
bread, vegetables and fruit liberally, one and a half ounces of 
sugar and five ounces of fat daily. 

Mineral Waters. — In general alkaline waters are to be pre- 
ferred. These are very numerous in the United States. 
Among them may be mentioned the Buffalo, Londonderry and 
Waukesha waters. 

The writer knows from experience the diuretic value of 
Waukesha water, having tested it in a case where the patient 
collected and measured the twenty-four hours' urine for 196 
consecutive days. On hydrant water this patient voided less 
urine than water taken ; at Waukesha more urine than water 
taken, the quantity increasing from twenty-five to thirty 
ounces per twenty-four hours to 100 ounces in a short time. 

In cases associated with excessive deposits of uric acid the 
White Rock L,ithia water may be used or French Vichy. 
Where gastric symptoms or constipation are a feature French 
Vichy water is certainly useful. 

On the Pacific coast McNutt recommends the Napa Soda, 
Coronado, and Bartlett waters. 

Not infrequently thorough washing out of the kidneys ac- 
complished by ingestion of large quantities of water does 
great good. In one or two cases, which the author has seen, 
ten to twenty glasses daily of the still Londonderry Lithia 
water produced decided amelioration, albumin, casts and crys- 
tals diminishing in marked degree, and not increasing again 
after the quantity was lessened, Geneva water has also done 
the same thing in other cases. 

In general, patient if dropsical should not drink more water 
than he voids urine for fear of increasing the amount of 
dropsy. 

Climatology. — When the patient has recovered suffi- 



CLIMATOLOGY. 181 

ciently to be able to travel, he may with benefit be removed 
to a mild, dry, equable climate where he can be outdoors most 
of the time without danger. Care must be taken, however, 
not to seek too high an altitude nor a locality which is all 
climate without comfort. On this account Southern California 
is, on the whole, to be recommended in the locality between 
San Bernardino and Los Angeles. A well-appointed sani- 
tarium is of course preferable to the ordinary hotel. 

The writer greatly prefers Southern California (continuous 
residence) for the severe cases. Several of his patients are 
not only improving there, but able to work at their business 
or profession, though totally incapacitated at home in the 
Mississippi Valley. Patients who come home, under the im- 
pression that they have recovered, have found it necessary to 
return, and the severe symptoms subside again in the more 
equable climate. 

Every specialist knows the tendency of exacerbations to set 
in coincident with the violent changes of the weather near the 
Lakes and north Atlantic. 

Doctor Waddell speaks highly of Avalon on Catalina 
Island, off the California coast, as a resort for those with 
chronic nephritis, especially in summer, the peculiar situation 
of the town being well adapted for such patients. On the 
mainland the district including Claremont is suitable. 

Those who desire to break the long journey to California 
will find a pleasant and well-equipped sanatorium at Lincoln, 
Nebraska, under the charge of Dr. B. F. Bailey. 

It goes without saying that in all localities visited attention 
should be paid to a marked difference in temperature, if any, 
between the night and the day, and wherever possible sleep- 
ing rooms should be provided with facilities for warmth if 
needed at night, the patient with a woolen night-dress and 
the bed with blankets. 

Those who are able to travel abroad or take sea voyages 
may visit the following : 



182 CHRONIC NEPHRITIS. 

In the West Indies, the Barbadoes. In Europe, Pan, Cannes, 
Rome, Naples, Malta, Malaga. In Africa, Algeria and upper 
Egypt ; the dry plateau north of Cape Town. 

During the winter in America patients may go to Eureka 
Springs, in Arkansas ; to Tallahassee, Aiken, Thomasville and 
San Antonio. 

Patients whose hepatic functions are greatly deranged may 
when in Europe visit Vichy, Carlsbad and Marienbad for a 
time, and during the proper season at these resorts. Resi- 
dence on the border of the African desert (Sahara), as at 
Helouan, near Cairo, is said to have a favorable influence on 
the albuminuria of renal disease. 

Remedies. — Modern writers are somewhat skeptical as to 
value of drugs in the treatment of chronic nephritis, and have 
more confidence in diet and regimen. It is indeed difficult to 
ascertain the value of remedies in this disorder owing to the 
tendency toward remission of the symptoms from time to 
time. This tendency toward remission may be the cause of 
misplaced confidence in a remedy when used just before the 
remission takes place. Certainly in no other disorder is there 
a greater field for the empiric. The writer seldom sees a 
patient with chronic nephritis who has not tried some secret 
nostrum, and who reports that it did him " a great deal of 
good for awhile, and then seemed to lose its effect." The sale 
of these preparations throughout the United States is very 
large, and the confidence of the public in them seems to be as 
great as the sale. Moreover, when in addition to the nostrum 
directions for diet and hygiene are given the latter undoubt- 
edly help the former very materially. 

In spite of the value, which is undoubted, of diet and hygiene 
the writer still clings to the hope of discovering the constitu- 
tional remedy for the individual in question. There is no 
doubt so far as clinical experience goes to show that the indi- 
vidual has his drug as he also has his diet, his regimen, and 



SYMPTOMATIC TREATMENT OF CHRONIC NEPHRITIS. 183 

his climate. How or why the drug acts when it does act is a 
matter with which we are not directly concerned in these 
pages. 

In chronic diffuse nephritis without induration we find 
about the same drugs used by various practitioners of internal 
medicine as in acute nephritis. 

Symptomatic Treatment. — Ferrum, Arsenicum, Canthar- 
ides, Mercurius cor., Apis, Nitric acid, Nux vomica, Phos- 
pherus are the remedies, as well as others mentioned under 
acute nephritis whenever acute exacerbations appear. Of 
these the writer relies chiefly on iron and arsenic. 

Ferrum. — The indications have already been given under 
acute nephritis. This drug is used more than any one other 
by the writer. 

Of the different preparations of iron Basham's mixture and 
Boudreaux's syrup or pills have proved by far the most ser- 
viceable. Basham's mixture (acetate of ammonium and iron) 
prepared by a good pharmacist so as to make a clear solution 
is given in doses of from one to two fluidrachms four times 
daily in plenty of water, continuously for months if necessary. 
Boudreaux's syrup or pills of the protochloride of iron seems 
especially efficacious in the case of anaemic women. The 
dose of the syrup is the same as that of Basham's mixture. 
A preparation known as haemoglobin with or without arsenic 
has appeared to be of therapeutic value in one or two cases. 
In cases in which the above are for any reason not well to- 
lerated Hensel's iron sometimes does admirably, or the pre- 
paration known as hemapeptone. It should not be given 
when there is high tension or when digestive disturbances 
are marked. The writer has seen oedema and albuminuria 
decrease and strength improve in a number of cases, appa- 
rently due to the action of iron. Ferrum muriaticum is 
used by many practitioners for chronic nephritis. 

Arsenicum. — When there are the usual symptoms, weak- 



184 CHRONIC NEPHRITIS. 

ness, restlessness, anguish, thirst for small quantities, dark, 
cloudy urine, nausea, anasarca and headache. All these 
symptoms are aggravated by warmth. This remedy acts well 
in chronic nephritis due to scarlet fever or malaria, and espe- 
cially in large white kidney, and when there is hydro thorax- 
The writer uses the second decimal trituration of Arsenicum 
album or the iodide in cases where waxy casts are found, also 
Hemoglobin with Arsenic in the case of anaemic women. 
Goodno suggests drop doses of Fowler's solution, three times 
daily, gradually increased if necessary to five drops. In cases 
complicated by pregnancy and miscarriage the Bromide of 
Arsenic in the third trituration is suggested by Dr. Searle, of 
Brooklyn. Next to Ferrum the writer uses Arsenicum most, 
and sometimes alternates it with the former. 

Cantharides may be given when the urine is scanty, dark, 
highly albuminous, micturition frequent and perhaps painful, 
stomach irritable and dropsy general. Use the lower poten- 
cies or even a good tincture in drop doses, three times daily, 
gradually increased to ten times, as suggested by Goodno. It 
is useful in relieving headache, delirium and coma in the early 
stages of chronic nephritis. There is mental stupor, drawing, 
tearing pains in the region of the kidney, thirst and aggrava- 
tion of urinary symptoms by drinking water. 

Apis is suggested when oedema of the lids is a feature, with 
scanty or suppressed urine in acute intercurrent attacks. 
This remedy is also to be thought of when there is much 
albumin still in the urine with but few casts, and few or no 
other symptoms of the disease. Use the third decimal tritur- 
ation of Apium virus. 

The writer has seen, however, thus far little benefit derived 
from use of Apis in chronic nephritis, unless in alternation 
with Apocynum or Sambucus in cases of dropsy. 

Mercurius corrosivus is to be used when there is general 
oedema, when the patient is anaemic, weak, restless, urine 
highly albuminous and still rather scanty, stomach and 



SYMPTOMATIC TREATMENT OF CHRONIC NEPHRITIS. 185 

bladder irritable, pulse quick and feeble; especially in syphilitic 
cases. Goodno advises doses of one or two drops of the third 
decimal dilution every three hours. Mercury was regarded 
by Dr. H. B. Millard as indispensable in the treatment of this 
class of cases. He advised Mercurius corrosivus and also the 
Protiodide and Biniodide. 

Nux vomica and Nitric acid when gastric symptoms are 
conspicuous. Nux vomica for irritable, morose patients, Nitric 
acid in cases where there is great weakness especially in the 
morning. 

Phosphoric acid when there is excessive loss of flesh and 
strength or after dropsy has been removed, and the patient is 
weak. 

Phosphorus. — Weak empty feeling in the whole abdomen; 
poor memory ; fatty casts abundant in the urine ; painless? 
watery diarrhoea, dimness of sight, hoarseness, pneumonia, 
jaundice, fatty degeneration of kidneys and liver, tuberculosis, 
caries. Use the third decimal. 

Potassium chlorate. — Progressing cases where anaemia, 
breathlessness, palpitation, scanty urine, and marked albu- 
minuria are features. 

Protonuclein may be given as a constitutional remedy in 
doses of four three grain tablets four times daily until head- 
ache appears from its use, when the dose is reduced to three 
times or twice daily and continued for a long period. 

Dr. B. B. Vaughan reports to the writer a case in which he 
gave this remedy in a supposedly hopeless case with appar- 
ently good effect, recovery taking place in a few weeks ; anti- 
phlogistine was applied to the region of the kidneys fresh 
every twenty-four hours and in addition to the Protonuclein, 
Arsenicum 3X and Baptisia were given. 

Strophanthus according to Royal is serviceable in dropsical 
cases of chronic diffuse (non-indurative) nephritis. When 
given in either the 2x or 3X the first effect is an increased 
flow of urine, decrease of the dropsy, also of albumin, casts 



186 CHRONIC NEPHRITIS. 

and crystals. And what is of greater significance, the im- 
provement thns secured lasts for a remarkably long time be- 
fore the disease resumes its fatal course. 

Terebinth is the remedy in cases of acute intercurrent at- 
tack following exposure to cold, or in hsemorrhagic cases 
where albumin and blood appear in increased quantity in the 
urine as soon as the patient gets up and moves about. Use 
the lower potencies or drop doses of the oil increased gradually 
to not more than five minims. 

Apocynum, Aurum muriaticum, Digitalis, faborandi and 
Glonoin are likely to be needed sooner or later in the course 
of the disease. Helonias, Hellebore, Antimony, Belladonna, 
Cuprum, Acetic acid, Stramonium, Erigeron, Millefolium, 
Coccus cacti, Pichi and the Iodide of potassium have been 
commended by various writers for special use in certain cases. 
It may happen, that before good results can be obtained from 
the use of remedies, the bowels must be regulated by use 
of Carlsbad Sprudel salt, Podophyllin, Leptandrin, Sulphur or 
Nux. 

As a palliative the writer has used Lactate of Strontium in 
connection with milk diet when albuminuria is stubborn. 

Use five drop doses of the Paraf-Javal solution, increasing 
rapidly if tolerated by the stomach to doses of a fluidrachm 
four times daily. 

This drug was recommended at one time as of service in 
reducing the amount of albumin in the urine, but modern 
writers doubt its efficacy. In several cases where the writer 
has used it albumin has certainly diminished in amount for 
the time being, but whether due to diet and regimen or to the 
drug alone can not be said. 

SPECIAL THERAPEUTIC MEASURES. 

Cases of moderate severity, if taken in time, will sometimes 
yield under treatment already described, and either a relative 



TREATMENT OF DROPSY. 187 

cure takes place, or occasionally an absolute recovery. Obsti- 
nate cases resisting general treatment develop special features, 
which imperatively demand special therapeutic measures, 
though the relief obtained be but temporary. Even in these 
severer cases recovery sometimes takes place when least 
expected. 

Troublesome Features. — The special features likely to 
cause trouble are, in usual order of frequency, the following : 

i. Dropsy. 

2. Dyspnoea. 

3. Circulatory and cardiac troubles. 

4. Gastro-intestinal disorders. 

5. Uraemia (convulsions). 

6. Renal hematuria. 

7. Persistent albuminuria. 

Treatment of Dropsy. — The methods by which dangerous 
dropsy may be reduced are the following, in order of efficacy : 

1. By sweating and purging (diaphoresis and catharsis). 

2. By stimulating the kidneys (diuresis). 

3. By increasing the activity of the circulation. 
Diaphoresis. — Hot baths, vapor or dry, hot packs, alcohol 

sweats, jaborandi. 

Sweating may be brought about by the warm bath, as al- 
ready described, by the vapor bath, hot-air bath, alcohol 
sweat, or hot wet pack. 

Alcohol sweats are given by saturating flannels with 50 
per cent, alcohol, wrapping them round a jug of hot water, 
and also round hot bricks. The water jug is placed under 
the patient's flexed limbs, and the bricks at his side, not near 
enough to burn. All, including the patient, are wrapped in 
flannels. 

Vapor baths or hot-air baths are not always well borne by 
feeble or elderly patients. Warm baths, as already described, 
are safer. 

In giving the warm bath the temperature should be about 



188 CHRONIC NEPHRITIS. 

ioo° F. when the patient is put into it ; then gradually in- 
creased to 104 or 106 F. and the patient allowed to remain 
in it for half an hour or more, following which he should be 
well-wrapped for two or three hours. 

The use of Jaborandi in connection with other methods of 
sweating has been described under Acute Nephritis. It 
must be used with great caution in chronic nephritis and al- 
ways supplemented by digitalis or hypodermics of brandy or 
ether if necessary. 

The hot wet pack may be given to patients with whom the 
warm bath disagrees or for whom it is impracticable. A large 
double blanket is immersed for a few minutes in water of a 
temperature just below boiling, wrung out quickly and wrapped 
about the patient, leaving the head exposed. The patient is then 
put to bed and well covered with dry blankets for two hours, 
during which time he should be given hot drinks freely, or 
barley water or rice water. He is then removed from the 
pack, thoroughly rubbed and placed in warmed dry blankets. 

The hot air bath is useful on account of the ease with which 
it can be administered. It is frequently all that is necessary 
in starting the perspiration in cases where the heart's action 
allows use of it, but in feeble or elderly patients it may be 
dangerous. The writer has seen it produce cardiac failure in 
one or two cases of weak, enfeebled old men, so that strych- 
nine may be necessary for administration when such an un- 
toward event takes place. The hot air bath may be given by 
placing an alcohol lamp on the floor, near the bed, and carry- 
ing a funnel bent at right angles from the lamp up under the 
bed clothing which must envelop the patient closely; a light 
cradle may be extemporized to support the bed clothing if 
desired. Should the skin remain hot and dry a warm, stimu- 
lating drink will usually start the perspiration, or a hypo- 
dermic of pilocarpine may be given in dose i-ioth of a grain, 
repeated in twenty minutes. 

The writer has been called on occasionally to give a hot 



DIAPHORESIS. 



189 



bath to a patient in remote localities where facilities for a bath 
of almost any kind were lacking. The best substitute which 
was thought of was to have the patient sit on a cane-seat chair 
or one with a perforated seat, and to place the alcohol lamp 
under the seat of the chair while the patient and chair were 
inclosed in a blanket wrapped around the patient's neck, leav- 
ing the head exposed. In spite of the danger of setting fire 
to nearly everything, I have several times succeeded in bring- 
ing about satisfactory diaphoresis by this crude means. 

A point of importance about the administration of the hot 
air bath is that it must be repeated in cases where the skin 
has been dry and inactive for some little time. In a case in 
which no history of free perspiration for a month past could 
be had, the first hot air bath produced almost no perspiration 
about the lower extremities, but the second one given on the 
following day brought about copious perspiration from head 
to foot. 

Purging may be accomplished by giving tablespoonful 
doses of a saturated solution of Epsom salt every three or four 
hours, or by giving two tablespoonfuls of the salt itself, dis- 
solved in half a glass of water, at 7 A. M. and 4 p. m., for five 
or six days, if necessary, or by giving a tablespoonful of 
Rochelle salt mornings before breakfast in cases more amen- 
able to treatment. 

Obstinately constipated cases may require i-ioth grain of 
Elaterium at night, or i-20th grain to i-8th grain every four 
hours till free watery stools are produced. Moreover, this 
drug is in some cases less weakening than massive doses of 
salts. 

Patients with chronic nephritis do not always tolerate salts 
as well as do those with passive congestion of the kidneys. 
Epsom salt should not be forced upon a patient who does not 
feel the better for it. 

If Elaterium produces nausea or vomiting, the alkaloid 
Elaterin may be given in doses of i-i6th of a grain every four 



190 CHRONIC NEPHRITIS. 

hours until frequent watery discharges are produced. Com- 
pound Jalap powder may be tried in doses of from thirty to 
sixty grains. If the hepatic functions are sluggish, Mercurius 
dulcis may be given in the form of tablets of the first decimal 
trituration, one tablet every hour at night, between dinner 
and bed time, followed by a Seidlitz power on rising in the 
morning. 

Saline or glycerine enemas may be useful in promoting the 
movement of the bowels. 

Diuresis. — On the whole Digitalis in the form of fresh in- 
fusion is the most reliable diuretic and the writer formerly a 
believer in the efficacy of apocynum has of late relegated the 
latter to second place. It goes without saying, however, that 
there are those on whom apocynum acts admirably and suffi- 
ciently. The dose of digitalis infusion is from two to four 
fluidrachms three times daily. 

A preparation known as Hydragogin is well worth consider- 
ing as a diuretic. The writer reduced extreme dropsy in a 
case of a year and a half standing with it in one week. Hy- 
dragogin contains tincture of digitalis and tincture of strophan- 
thus, together with solutions of scillipicrin, scillitoxin, and 
oxysaponin — in other words, digitalis, strophant bus, the active 
principles of squill and the glucoside oxysaponin. The re- 
markable diuretic action of the preparation is thought to be due 
to the support given by oxysaponin to the other remedies. 
Oxysaponin is a glucoside obtained from Herniaria Glabra 
and when administered alone excites diuresis and watery 
stools. 

Hydragogin is given in doses of fifteen drops in one-fourth to 
one-half pint of water every hour for thirty-six hours with the 
nausea, on a strict milk diet, unless it cause after the third dose 
patient malaise, weakness, loss of appetite and dislike of the 
remedy. In such a case discontinue for half a day, then give it 
in five or ten drop doses every two or three hours. When 
the full physiological effects of the remedy are evident, as 



DIURESIS. 191 

shown by copious watery stools and marked diuresis, it is 
discontinued- altogether for a brief period of time and then 
resumed in smaller doses at longer intervals as five to ten 
drops three times daily. 

Goldberg has used hydragogin for eight years in more than 
one hundred cases. His description of one noteworthy case 
is as follows : 

The patient, a man of 64 years, with gray hair and a flow- 
ing white beard, was sitting in a comfortable armchair, his 
face intensely red. He was laboriously gasping for air. The 
table at his side was literally loaded down with full and partly 
empty bottles of cognac, port wine, Burgundy, Champagne 
and similar liquors. Two nurses from the Elisabeth training 
school at Berlin stood at either side in their trim uniforms, 
and alternately administered some of the contents of the 
bottles in the endeavor to prevent the threatened collapse. 
Physical examination showed very considerable ascites, marked 
oedema extending from the feet up to the hips ; the apical im- 
pulse was evident in the mammary line and the sixth inter- 
costal space, the heart sounds were not attended by any mur- 
murs, the pulse beat ninety-two times per minute, frequently 
intermitting ; arterial movement was rigid ; diffusely scattered 
over the lungs moist rales were heard, the breathing was 
asthmatic. The patient passed J^-^2 litre of urine in the 
twenty-four hours, and once daily or every second day his 
bowels moved in response to drastic purgatives. For the 
past three weeks, also, the patient had not been to bed, his 
inability to assume the recumbent position compelling him 
to remain in his easy chair day and night. 

On Monday morning, February 13, the patient first took 
hydragogin. By Wednesday evening, the 15th, he had already 
passed 14300 c.c.m. of urine, not including the amount of 
water in the very frequent and liquid evacuations from the 
bowels ; the patient felt much better, and could lie in bed 
without any appreciable discomfort. By the following Satur- 



192 CHRONIC NEPHRITIS. 

day evening, February 18, the patient had passed somewhat 
more than twenty-four litres of urine, all swelling had disap- 
peared, and he felt so well that on the following Monday he 
went to his office on the floor below, and was able to attend 
to his business as usual. 

In this case of Goldberg's the condition of arterio-sclerosis 
was probably present. 

The writer's case, however, was one of chronic diffuse 
nephritis without induration, and with extreme oedema and 
ascites in a young woman without arterio-sclerosis. She had 
been gradually growing worse for eighteen months, until 
finally she was confined to the house. In a week from the 
time when she began taking hydragogin she was at her work 
again ; a slight degree of oedema persisted about the ankles. 

K. Tutschulte has used hydragogin in ten cases. His 
custom has been to begin with a small dose, five drops, every 
two hours, and gradually increase until the patient gets fifteen 
every two hours. [In one case, not renal, there was acute 
cardiac dilatation with murmurs at both apex and base, the 
result of chronic endocarditis, great ascites, oedema of limbs 
and face, but urine normal though scanty. There was intense 
headache, dizziness and dyspnoea. Ascites and oedema disap- 
peared in five days under treatment by hydragogin.] 

H. A. Watson in the Chicago Clinic for August, 1902, 
describes the action of hydragogin on a boy 12 years of age, 
suffering from chronic nephritis two years after an acute 
attack following scarlet fever. The usual measures for relief 
of dropsy, dyspnoea, etc., were tried without avail. Hydra- 
gogin in twenty drop doses, three times daily, gradually 
caused the disappearance of ascites and oedema, and diminu- 
tion in the amount of albumin. He also cites several other 
cases where its administration was beneficial. 

In order to overcome secondary heart failure it may be nec- 
essary in some cases to give heart tonics or stimulants as well 
as the diuretic, for example : 



TREATMENT OF DROPSY. 193 

Sparteine in one-grain doses of the first decimal trituration 
every three hours, or five grains of the second decimal every 
two hours ; or fluid extract of Corn Silk ten to twenty drops 
every two hours ; or Citrate of Caffeine in four- to eight-grain 
doses every four hours (alone or combined with Paraldehyde 
at night); or ten-drop doses of Adonis vernalis four times 
daily ; or Strophanthus in doses of two to five minims of the 
tincture. Strychnine, night and morning, T ioth of a grain in 
addition to catharsis and diuresis. 

Inasmuch as hydragogin contains both Strophanthus and 
Oxysaponin the above are not necessary when it is used. 

Apocynum is unquestionably a potent diuretic in many 
cases, but frequently it is necessary to give it in doses suffi- 
cient to produce vomiting and purging before its diuretic 
action takes place. The tincture is said to be better than the 
infusion for the reason that the cardio-kinetic principle of the 
drug is soluble in alcohol but not in water. The dose of the 
tincture is from fifteen drops to half a fluid drachm, or even 
more. The writer has seen patients who were nauseated by 
seven drops of the tincture, and again those who could take a 
teaspoonful without nausea and without diuresis. In one case 
diuresis was brought about by forty-drop doses of the tincture 
every three hours. 

In the less urgent cases of dropsy with the usual indica- 
tions for the drug it may be administered with benefit, begin- 
ning with small doses, five drops every three or four hours, 
and increased if necessary. The writer, however, is at a loss 
to account for its prompt action in certain cases and its failure 
in others unless it be that it is better suited to congestion of 
the kidneys than to inflammation. 

In order to obviate the unpleasant effects of Apocynum, 
Dr. C. A. Williams, of Chicago, combines it with Corn Silk 
and Wild Cherry as follows : Fresh alcoholic tincture of 
Apocynum, one fluid ounce; fluid extract of Corn Silk, two fluid 
ounces ; syrup of Wild Cherry, three fluid ounces ; dose, one 
teaspoonful every two to six hours as required. 

13 



194 CHRONIC NEPHRITIS. 

The general indications for the use of Apocynum are said 
to be as follows : There is present a weak, gone feeling at the 
pit of the stomach, so that the food is not well borne ; there is 
much thirst, and drinking is attended with great distress. 
The heart's action is irregular, and the pulse is slow. 

The writer has, however, found it serviceable where none 
of these indications except the cardiac ones were present. 

Macy's diuretic mixture (used by Iyaidlaw and others) is 
as follows : The tinctures of Apis, Apocynum, Helleborus 
mixed in equal proportions. Ten drops of this mixture are 
mixed with four ounces of water, and one teaspoonful given 
every hour or two. 

Theobromine either alone or in the form of diuretin or 
agurin is used as a diuretic. In the writer's experience this 
drug is not to be depended on unless a considerable portion of 
the kidneys is intact, hence is of more value in cardiac drop- 
sies or in alternation with other diuretics. 

A favorite diuretic is Cream of tartar in doses of from 
thirty to sixty grains or more, three times daily, in a pint of 
lemonade. 

In desperate cases after failure of other remedies a pill of 
Calomel, Squill and Digitalis, one grain each, is sometimes 
effective, as suggested by Dr. R. H. Fitz, of Boston. 

The Acetate and the Citrate of Potassium are useful diuret- 
ics. A very common combination is that of Acetate of Potas- 
sium and Digitalis. Sometimes both the acetate and citrate 
are given together in solution. 

Bandaging. — The tense abdomen is to be annointed with 
oil, covered with linen soaked in oil, and over this a flannel 
bandage is applied. The lower limbs, which are cedematous 
and usually cold, are treated in like manner, being wrapped 
in oil-soaked linen, over which a flannel bandage is drawn 
with moderate pressure, care being taken that it is not too 
loose. By this means it is usually accomplished that the 
limbs feel comfortably warm by the following day. 



TREATMENT OF DYSPNCEA AND HEADACHE. 



195 



Normal Salt Solution. — This may be used after colon 
flushing as a means of promoting diuresis. 

Puncture. — If the dropsy resists all treatment, after delay- 
ing as long as possible puncture the legs above the ankles or 
make several moon-shaped incisions just below the internal 
malleolus. The incisions may, however, refuse to heal and 
the dripping, as in a case of bursting, proves a serious burden 
to the patient. Puncture of the scrotum often gives much 
relief and in cases which the author has seen has not pro- 
duced ill results. 

Paracentesis. — In some cases where the patient is unable 
to tolerate drugs or the latter are inefficient it may be neces- 
sary to perform the operation of paracentesis abdominis. 

Treatment of Dyspnoea. — Bliminative measures are most 
useful. The writer cannot recollect a case of dyspnoea which 
was not at least ameliorated by the production of copious 
watery stools as by use of Epsom salt or Elaterium. 

Jaborandi may be needed in order to promote diaphoresis, 
but it must be very carefully used. Diuretics as already dis- 
cribed will aid in the case. 

Strychnine may be needed when the heart is weak and 
Glonoin when there is high tension. 

Aspidospermine has been used successfully in the treatment 
of dyspnoea ; it may be given in doses of two to four metric 
granules (eVth grain each), together with five to sixty drops of 
the fluid extract of Passiflora, every ten or fifteen minutes 
until relief is to be had. For the weakness after an attack 
the Arsenate of Strychnine in doses of one metric granule 
( T ^ T th grain) may be given every fifteen minutes until the 
patient is stronger, then four times daily for a few days. 

Treatment of Headache. — Headache in this disorder may 
be the result of high tension from toxaemia or of hepatic 
origin. In the former case Glonoin, the Nitrites and the 
Chloride of Gold and Sodium may palliate, together with elim- 
inative measures. 



196 CHRONIC NEPHRITIS. 

In a case which the writer treated of violent sick head- 
ache with vomiting the attacks were much decreased in 
severity and diminished in frequency by administration of 
Fairchild's pepules of Ox-gall, Pancreatin and Nux vomica. 
The patient was a young woman of sallow complexion with 
movable right kidney and chronic diffuse nephritis without 
induration in both kidneys, as ascertained by use of the Harris 
segregator. The patient had been tormented with these head- 
aches, occurring at irregular intervals every week or so for 
months and the benefit derived from the pepules seemed un- 
questionable. 

Mercurius dulcis, Euonymin, Carlsbad Sprudel salt and 
Sodium Phosphate maybe tried in cases of apparently hepatic 
origin. 

Strict abstinence from meat is to be enjoined in these cases, 
but alone will not prevent the attacks. 

Gastro-intestinal Disorders. — Obstinate vomiting is some- 
times a distressing feature. A certain amount of vomiting is 
regarded as an effort of nature to rid the circulation of toxins 
and should not be interfered with. But when there is per- 
sistent retching and the patient is growing weak, effort must 
be made to relieve the condition. Ch lore tone in five grain 
doses followed by a drink of cold water is sometimes efficacious, 
especially in alcoholic cases. (See Chronic Interstitial 
Nephritis.) 

It is said that Apomorphine, ^Vth grain hypodermically, 
will sometimes relieve it. A dose of four drops fl. ex. Ergot 
and five of Chloroform in a teaspoonful of water relieved one 
of my cases for the time being, but reliance must in general 
be put upon eliminative treatment, sweating, or Jaborandi. 

Increased Arterial Tension. — Whenever the pulse becomes 
tense and it does not yield to symptomatic treatment very 
speedily, vomiting, headache, dyspnoea and convulsions may 
appear, so that to forestall the development of these symptoms 
we must use Nitroglycerine T ^th grain, Aconite first decimal 



TREATMENT OF UREMIA AND HEMORRHAGE. 197 

or Morphine if imperative, hypodermically, one-eighth, of a 
grain ; Chloral hydrate or Iodide of potassium may be service- 
able occasionally. 

Cardiac Weakness. — This may require Digitalis, Strophan- 
thus, Spartein, Caffeine, Adonidin, Convallaria, Cactus. 
Hypodermics of T -Jo- th grain of Glonoin may be used ; Digi- 
talis in five to ten drops of the tincture, or Convallaria in like 
dose ; Cactus in like dose, or even twenty to thirty drops, plus 
Troth grain of Strychnine as suggested by the late E. M. Hale. 

Spartein is given in doses of one grain of the first decimal 
trituration every three hours ; Caffeine in doses of from two 
to five grains every three hours. 

Uraemia. — Uraemic symptoms as nausea and vomiting, 
drowsiness, stupor, coma or convulsions are to be treated as 
described under Acute Nephritis. There is usually more 
danger in the use of Jaborandi in chronic nephritis than in 
acute, hence necessity for caution. It should not be given 
where there is pulmonary oedema. 

To prevent uraemic convulsions Searle gives one-half pint 
of lemon juice each twenty-four hours, in divided doses mixed 
with water. 

In chronic poisoning of long standing, milk diet, laxatives 
and hot air bath is about all that the patient can stand when 
his kidneys have become incapable of performing their func- 
tions. 

In the last stages of uraemia when there is eclampsia intra- 
muscular injections of saline solutions may be used. 

For uraemic twitchings Glonoin may be used. Lactate of 
strontium in fifteen- to twenty-grain doses seems to be service- 
able in uraemic cases. 

Hemorrhage. — In the writer's experience (confirmed by Dr. 
McMichael, of New York) in many cases tincture of Thlaspi 
bursa pastoris in thirty-drop doses, four times daily or oftener, 
will stop excessive flow of renal blood when other agents fail. 
Its use may need to be kept up for several weeks. Other reme- 



198 CHRONIC NEPHRITIS. 

dies are Turpentine, Erigeron, Millefolium, Coccus cacti and 
Pichi, to say nothing of the crude astringents Trillium, 
Geranium (fifteen to thirty drops), Hamamelis (thirty to 
ninety drops), Gallic acid (two to ten grains), Ergot (three 
grains of the extract), fluid extract of Red Gum. 

Ergotinine may be used in persistent hsematuria. It often 
fails, however, to stop the hemorrhage. 

Electricity. — The use of static electricity for the treatment 
of chronic nephritis is now much in vogue. 

Neiswanger, of Chicago, reports a number of cases cured 
by this means. 

Surgical Measures. — R. Harrison has called attention to 
the improvement in certain renal cases after exploratory oper- 
ation, in which no recognizable cause had been discovered for 
the clinical symptoms, and said it seemed reasonable to infer 
that these results were due to the relief of renal tension* 
Different from the times of Bright, we can now see and ex- 
plore a living kidney with ease and safety in situ. 

The following may be regarded as some indications for re- 
lieving tension surgically : Progressive signs of kidney de- 
terioration ; suppression of urine or approaching that state ; 
marked disturbance of the heart and circulatory apparatus 
arising in the course of inflammatory renal diseases. 

Harrison splits the capsule along the convex border ; or, 
if indications for exploration of the kidney are present, he ex- 
tends the cut through the kidney substance into the pelvis. 
Numerous punctures over the surfaces of the organ may be 
made. A drainage tube is then inserted and the wound is 
sewed up about it. Drainage is essential, from seven to ten 
days usually, as there is always considerable discharge. It is 
a matter of indifference as to which kidney is operated upon 
unless there is something to indicate it, such as pain, since 
the relief of tension in one kidney relieves the other. 

Edebohls, of New York, performs the operation of Capsular 
nephrotomy for the cure of Bright's disease. Primrose, of 
Toronto, has also performed the operation. 



SURGICAL MEASURES. 199 

Primrose's case was as follows : A child 10 years of age 
suffered from nephritis. The history is obscure as to the on- 
set of his illness, but for six months before he had general 
anasarca and ascites. During that time paracentesis abdom- 
inis had been performed seven times. On admission to the 
hospital on November 8, 1901, the urine contained 1.6 per 
cent, of albumin, the abdomen was enormously distended with 
fluid and there was great swelling of the face and oedema of 
the extremities. The lad's general condition was considered 
very serious and a gloomy prognosis was given. Paracentesis 
abdominis was performed and 180 ounces of fluid drawn off 
from the peritoneal cavity. The urine, which contained 
the large amount of albumen indicated, also contained numer- 
ous hyaline, granular and epithelial casts. 

On November 21st he cut down upon the right kidney in 
the loin ; he found it much enlarged, and made an incision 
two inches long through the capsule and subsequently drained 
the lumbar wound for a fortnight. As a result of the opera- 
tion the amount of urine secreted in twenty-four hours gradu- 
ally increased from fourteen ounces in twenty -four hours to 
forty ounces on the seventh day after the operation, while the 
percentage amount of albumin diminished from 1.6 per cent. 
to 0.8 per cent. The child's condition, however, did not con- 
tinue to improve and it appeared evident that permanent relief 
of symptoms had not been secured. One was encouraged, 
however, by the profound effect produced upon the condition 
of the patient by the simple operation upon the right kidney 
of splitting the capsule, and it was therefore thought justifiable 
to perform a more extensive operation upon the left kidney. 
Accordingly, on December 20th, forty-two days after admis- 
sion to the hospital, he cut down upon the left kidney and re- 
moved the kidney capsule in its entirety. The child, though 
critically ill after the operation, eventually recovered. 

The disappearance of albumin and casts from the urine 
after operation on the kidney has been noted by many observ- 



200 



CHRONIC NEPHRITIS. 



ers, such as Rose, Newman and Ferguson. We are mainly 
indebted, however, to Harrison, in England, and to Edebohls, 
in America, for pointing out the bearing which these results 
have on the question of the possibility of curing albuminuria 
by surgical means. {Pediatrics.) 





Photograph of patient on November 19, 
1901 , two days before the first opera- 
tion on the kidney. 



Photograph of patient on February 3. 1902, 

forty-five days after the last operation 

on the kidney. 



Fig. 15. 



Edebohls performs the operation as follows : 
" Excision of the renal capsule proper is performed as fol- 
lows : The patient is placed prone upon the table, with the 
kidney air cushion underlying and supporting the abdomen. 
Both kidneys are thus rendered accessible to operation with- 
out the necessity of changing the patient's position. An in- 
cision is carried from the twelfth rib to the crest of the ilium 



SURGICAL MEASURES. 201 

along the outer margin of the erector spinae, without opening 
the sheath of that muscle. The fibers of the latissimus dorsi 
muscle are bluntly separated in the direction of their course 
without cutting. The ilio-hypogastric nerve is sought for 
and drawn to one side or the other, out of the way of harm. 
Division of the transversalis fascia exposes the perirenal fat. 
This is divided over the convexity of the kidney until the 
capsule proper is reached. The fatty capsule is now bluntly 
separated everywhere from the capsule proper, the dissection 
advancing on either aspect and around both poles of the kid- 
ney until the pelvis of the kidney is reached. Now and then 
the fatty capsule may be found so thickened and adherent, as 
the result of chronic perinephritis, that the scissors or knife 
may be required to separate it from the capsule proper. The 
kidney with its capsule proper is next lifted from its fatty 
capsule bed, and, if possible, delivered through the wound. 
The capsule proper is divided on a director along the entire 
length of the convex external border of the kidney and clean 
around the extremity of either pole. Each half of the capsule 
proper is in turn stripped from the kidney and reflected 
toward the pelvis until the entire surface of the kidney lies 
raw and denuded before the operator. 

In separating the capsule proper from the kidney, care must 
be exercised not to break or tear away parts of the kidney, 
which is often both very friable and very firmly connected 
with its capsule proper. The stripped-ofl capsule proper is 
next cut away entirely, close to its junction with the pelvis 
of the kidney, and removed. Delivery of the kidney makes 
this otherwise difficult work easy. If the kidney cannot be 
delivered, the capsule proper must be entirely peeled off the 
kidney by the fingers in the bottom of the wound, and excised 
as far as possible, any remaining portion being simply reflected 
backward around the root of the kidney, where it will curl up 
and stay. The kidney is dropped back into its fatty bed and 
the external incision is closed. Drainage, except when the 



202 • CHRONIC NEPHRITIS. 

parts are extremely cedematous, is dispensed with. After both 
kidneys have been thus operated upon, the dressings are ap- 
plied and the patient is put to bed. 

Renal decapsulation is not directly and forthwith curative 
of chronic Bright's disease, but it leads to a cure or improve- 
ment of the disease by establishing circulatory conditions es- 
sential to such cure or improvement. 

The final disappearance of albumin and casts may require 
from one to twelve months. It is also possible that cicatricial 
formation may lead to trouble later on. 

A practical difficulty in the way of this operation is the un- 
willingness of many patients to submit to it owing to the fact 
that Bright's disease being a disorder in which remissions fre- 
quently occur the patient unless badly dropsical does not 
realize the gravity of his condition. 

[It may be observed in connection with this operation that 
Mongour has decided to abandon fixation of the omentum in 
the hope of re-establishment of the portohepatic circulation in 
cases of ascites due to cirrhosis of the liver.] 

In regard to the anaesthetic employed Edebohls says : 

" Contrary to general opinion as to the safest anaesthetic for 
renal operations, ether was used in all but one of the eighteen 
cases, and it would seem from the results that the fear of ether, 
as an anaesthetic in the presence of renal disease, is not well 
grounded. 

"Ether was the anaesthetic employed in all of my operations 
but one, on these eighteen sufferers from chronic Bright's dis- 
ease. Upon many of them I performed operations additional 
to the kidney operation, always under ether, and in not one 
instance was the slightest untoward effect observed. Case 
No. 1 8 was operated upon under combined nitrous oxide and 
oxygen anaesthesia conducted by Dr. Thomas L. Bennett. I 
see no good reasons why any surgeon should not use, in his 
operations upon the kidney, the same anaesthetic to which he 
is accustomed in his operative work generally. 



SURGICAL MEASURES. 



203 



" Personally, I would prefer, especially in cases of far ad- 
vanced Bright's disease, nitrous oxide and oxygen, provided 
I could always command the services of an expert like Dr. 
Bennett to administer the combined gases ; otherwise I would 
choose ether. My third choice would be spinal cocaine anaes- 
thesia, which I have found particularly well adapted for work 
upon the kidneys. 

" There has thus far been no mortality in my operations 
upon the kidneys of patients affected with chronic Bright's 
disease. All of my patients recovered from the operation and, 
as far as my knowledge goes, all but two are alive to-day. 
One of the two died after an operation for ruptured tubal 
pregnancy, performed by another surgeon, exactly one year 
after my operation on her kidneys ; the other succumbed to 
a hysterectomy, also performed by another surgeon, eight 
years after my operation on her right kidney." {Era.) 

The writer's experience in regard to chronic Bright's dis- 
ease is, however, that it is quite as frequently a question of the 
condition of the lungs and breathing apparatus generally as 
of the heart, and that in elderly patients it is exceptional to 
find one in whom both the respiratory and circulatory systems 
are in fit condition for anesthesia. 



CHAPTER IX. 

CHRONIC DIFFUSE NEPHRITIS WITH INDURATION. (CHRONIC 
INDURATIVE NEPHRITIS). 

Definition. — A form of chronic diffuse nephritis in which 
the new cells in the stroma proceed to form mature connective 
tissue resulting in induration or hardening of the kidney. 
Round cell infiltration and connective-tissue proliferation in 
the stroma are marked in this variety of renal disease. 

Forms. — There are three forms, namely, secondary chronic 
interstitial nephritis, primary chronic interstitial nephritis 
and arteriosclerotic kidney. The first is the most frequent 
type of all chronic renal diseases — according to Riesman. 

SECONDARY CHRONIC INTERSTITIAL NEPHRITIS. 

Synonym. — Atrophy of the kidney. 

This form represents an advanced stage of chronic diffuse 
nephritis without induration, in which, as previously remarked, 
there are evidences of connective tissue proliferation. If a 
case of chronic diffuse nephritis without induration lasts long 
enough, the connective tissue proliferation becomes more 
marked and results in an increased consistence of the kidney 
and not infrequently in a reduction in size. Intermediate 
stages may be found, so that it is not always possible to draw 
a sharp line between the forms without induration and those 
with it. Inasmuch as some cases of diffuse nephritis without 
induration take a subacute rather than a chronic course, the 
line between even acute nephritis and chronic with indura- 
tion is not always to be sharply drawn. 

Secondary chronic interstitial nephritis is, however, more 
likely to follow the large mottled kidney than the large 



SECONDARY CHRONIC INTERSTITIAL NEPHRITIS. 



205 



white kidney, inasmuch as the patient lives longer with the 
former disease than with the latter. 

Pathologic Anatomy. — The Kidneys. — Size depends upon 
duration of disease and amount of blood in the vessels, hence 
may be normal, larger or smaller than the normal. The con- 
sistence is greater than normal. The color dark-red, mottled 
or grayish yellow. 

The Renal Surface. — Either smooth or slightly granular ; 
presence of cysts not unusual. 

The Capsule. — Strips easily except in spots. 

Section. — Shows the cortex variable in width ; in some 
places wider than normal, in others narrower. In appearance 
the cortex is opaque and mottled. 

In contracted kidney there are always bits of normal tissue 
interspersed between the numerous separate foci of disease. 

Pathological Histology. — The principal change is in the 
cortex whose glomeruli are especially affected. Such as escape 
degeneration are in many cases larger than normal. There is 
more or less degeneration and atrophy of the tubules, some of 
which are replaced by connective tissue and others dilated 
into cysts. The stroma is increased in width by round-cell 
infiltration and new formation of connective tissue. Changes 
in the stroma are secondary to parenchymatous degeneration. 

Etiology. — The cause of this disease is chronic diffuse 
nephritis without induration, of which it represents an ad- 
vanced stage. 

Clinical Features. — Left ventricle hypertrophied, and, if 
disease lasts long, dilated. 

Aortic second sound accentuated. Pulse tension increased. 
Dyspncea frequent, may be asthmatic in character, due partly 
to uraemia, partly to pulmonary cedema, or hydrothorax. 
Ursemic symptoms more severe than before induration ; dys- 
entery, delirium, coma, convulsions, paralysis, retinitis not so 
common as in the interstitial form. There is less cedema 
than before induration sets in. 



206 CHRONIC DIFFUSE NEPHRITIS WITH INDURATION. 

Bronchitis and chronic pulmonary oedema occur in advanced 
stages as a result of cardiac insufficiency. For other clinical 
features see Primary Chronic Interstitial Nephritis. 

The Urine. — We find the quantity of urine usually more 
abundant, specific gravity lowered, urea deficient, albumin 
still abundant, but not in such enormous quantity as before, 
casts not so numerous, fatty casts less frequent, and waxy 
casts present. There are also red blood corpuscles, hyaline 
casts and fatty epithelia present. 

Dangers. — The dangers in this lesion are cardiac dilatation 
and insufficiency, resulting finally in dropsy, exhaustion or 
heart failure, and urcsmia. 

Duration. — The disease may last from one to three years. 

The Prognosis. — Unfavorable. 

Treatment. — See Primary Chronic Interstitial Nephritis. 

PRIMARY CHRONIC INTERSTITIAL NEPHRITIS. 

Synonyms. — Contracting or contracted kidney, granular or 
red granular kidney, gouty kidney, chronic fibrous nephritis, 
granular atrophy or degeneration of the kidneys, red atrophy 
of the kidneys, chronic inter-tubular nephritis, third stage of 
Bright's disease. 

Definition. — A form of chronic nephritis, often primary, of 
slow, insidious development, and in which the kidneys are 
hardened and often contracted to such an extent as to be evi- 
dent at post-mortem to the naked eye. 

Pathologic Anatomy. — The Kidneys. — Small, hard, granu- 
lar. May be one-third normal size, or even not much larger 
than the thumb-nail. May weigh as little as 50 grammes 
(775 grains). Asymmetric kidney not rarely found. The 
kidney is embedded in abundant adipose tissue, which may 
adhere to the capsule. The color is usually reddish. The 
surface shows cysts. 

The Capsule. — Firmly adherent; on removal tears the 
cortex. 



PRIMARY CHRONIC INTERSTITIAL NEPHRITIS. 207 

The Cortex. — Highly granular, reduced in width, in some 
places absent, of mottled color with reddish striae or. dots. 

The Pyramids. — Reduced in size, but relatively increased 
compared with the cortex, forming the greater part of the cut 
surface. Contains bands of fibrous tissue extending from the 
cortex. Calcareous infiltrations and urate deposits may be 
found. 

Section. — Shows, as above, the cortex diminished in size and 
the pyramids relatively increased. Cysts may be found in- 
volving the cortex principally, but may extend into medulla. 
The cut arteries stand out prominently and do not collapse- 
There is much fat in the renal pelvis. 

Striated uric acid infarctions in the pyramids are a very 
characteristic mark of the gouty contracted kidney. 

Pathologic Histology. — The features are an overgrowth of 
connective tissue and destruction of the glomeruli, principally 
in the cortex and especially marked in the labyrinth. There 
is marked increase of the stroma both in the cortex and 
pyramids, between the tubules, about the glomeruli and 
blood-vessels. The overgrowth is especially marked about 
the glomeruli and between the cortical tubules. The blood- 
vessels are thickened by endarteritis to a considerable degree, 
especially the smaller inter-tubular vessels. 

The change in the capillaries is an arterio-sclerosis, but in 
the larger vessels it is an hypertrophy ; the pathological con- 
dition is much different; in the capillaries new tissue is 
formed, and in the larger vessels there is an increase of all 
the normal tissues of the walls of the vessels. 

Etiology. — In many cases there is no history of previous 
acute renal lesion ; in a few a history of acute nephritis in 
childhood is obtainable. 

I. Hematogenous Causes. — The principal cause seems to 
be mild irritation of the kidneys acting continuously over a 
long period of time, especially from mal-assimilation of food 
due to irregular habits or worry, or even worry alone ; gout, 



208 CHRONIC DIFFUSE NEPHRITIS WITH INDURATION. 

the uric acid diathesis, alcohol, syphilis, malaria, lead poison- 
ing and that from other substances. In a few cases diabetes, 
especially in early life, leads to it. 

Elliott has pointed out that where there is chronic gastro- 
intestinal trouble, an increased amount of work is imposed 
upon the liver, with the result that the liver cells become 
gradually and progressively affected and eventually yield to 
irritation and prolonged over-functioning, permitting the 
poisons which reach them from the bowel, together with 
the products of disturbed hepatic function, to pass into the 
general circulation. The presence of these bodies in the 
blood disturbs vascular tension, and a high degree of renal 
irritation results from their elimination. He has called special 
attention to the insidious action of gastro-intestinal conditions 
resulting from chronic constipation, and to the effects of the 
toxines thus produced upon the kidneys, the disease being 
often far advanced before it was even suspected. 

Osier thinks lithemia a common cause in this country, as is 
gout in England. 

II. Non-hcematogenous Causes. — Due to prolonged obstruc- 
tion to the out-flow of urine from any cause, as stricture, en- 
larged prostate, hydro-nephrosis, cysts in the kidneys, or sec- 
ondary to pyelo-nephritis, especially that of nephrolithiasis. 
Localized cases occur following the healing of abscesses, 
wounds, infarcts, or gummas in the kidney. 

Clinically, we find lead, alcohol and uric acid three very 
common causes. Instead of uric acid the alloxuric bases may 
be the causative agents, according to Croftan, in all forms of 
nephritis with the exception of the form resulting from senile 
arterio-sclerosis. 

It may appear after severe acute articular rheumatism, and 
may be found combined with chronic endocarditis, valvular 
heart disease, or with chronic arthritis not of gouty origin. 

Herter thinks from 468 autopsies in which the weights of 
the kidneys were recorded that the belief that contracted 



PRIMARY CHRONIC INTERSTITIAL NEPHRITIS. 209 

kidney results from alcoholic excesses rests on a very insecure 
foundation. He found 13 per cent, of the small kidneys in 
the non-alcoholic group, 8 per cent, in the moderately alco- 
holic, and less than 6 per cent, in the alcoholic. 

On the other hand, he found 29 per cent, of the large 
kidneys in the non-alcoholic group, 45 per cent, in the 
moderately alcoholic group, and nearly 40 per cent, in the 
markedly alcoholic group. 

These figures go to support the writer's clinical observation 
of the occurrence of the large kidney in the case of patients 
who have led lives in which drink was a feature. 

Gluttony is recognized as a common history in cases of 
chronic interstitial nephritis. 

Occurrence. — It occurs most commonly in males who are 
over forty years of age. Cases occur also in children and in 
young people. Guthrie reports seven cases in children, 
Goodno two, Milligan one with retinitis. The writer has 
seen it in the case of but few women, much less frequently 
than in men. 

The patient is usually a man over forty years of age, be- 
longing to the well-to-do classes, with previous condition of 
robust health and addiction to nitrogenous diet and good 
living. Has, perhaps, gout, or is of gouty ancestry, with 
apoplectic family history. 

When the American humorist, Bill Nye, said that. u Bright's 
disease was an aristocratic ailment," he must have had in 
mind this form of nephritis. 

It may be present in persons who are apparently in good 
health, and its presence is not inconsistent in some cases with 
mental and physical activity. It is, as a rule, difficult to 
ascertain just when it began in a given case. 

It is frequently associated with general arterio-sclerosis ; it 
is probable that heredity has something to do with its develop- 
ment, as in some families it is as rife as tuberculosis in others. 

The relation of the disorder to a cold, moist climate was 
14 



210 CHRONIC DIFFUSE NEPHRITIS WITH INDURATION. 

pointed out by the late Dr. C. W. Purely. The writer sees 
more cases of it in Chicago than of any other form of nephritis. 

THE CLINICAL FEATURES. 

Relation to Pathology. — In this disease a previously healthy 
kidney is slowly attacked by some deleterious action, which 
results in the destruction of cell after cell of epithelium and 
islet after islet of tissue, together with partial replacement of 
the parts destroyed by a new formation of cicatricial tissue. 
We find, therefore, first: Renal insufficiency; second, rise in 
arterial tension now thought to be due to irritation from the 
uraemic poison; third, hypertrophy of the left ventricle, in a way 
compensatory, enabling the heart to do the extra amount of 
work required to keep up the excretion of urine ; fourth, weak- 
ening and dilatation of the heart. As a result of the increased 
arterial tension and cardiac hypertrophy, which goes hand in 
hand with the process in the kidney, there is polyuria, by 
means of which a sufficient quantity of urinary solids is voided 
to enable the patient to live for perhaps a long period of time, 
the diminution in total solids per twenty-four hours being not 
great as long as the work of the heart is sufficiently good. 
In spite of this, however, minute quantities of toxins retained 
for a long time in the body may suddenly, by cumulative 
action, cause an acute uraemic attack somewhat similar to the 
cumulative action of lead or mercury. This probably explains 
why it is that persons previously regarded as healthy may 
suddenly die of uraemia or cerebral hemorrhage. Eventually 
if the patient escape death from acute uraemia, two things 
may happen: Hither the left ventricle becomes weak or the pro- 
cess in the kidney reaches a point where not even the most 
vigorous efforts of the heart are sufficient to bring about com- 
pensation by way of polyuria. In the first case, the weakness 
of the heart is shown by the appearance of, first, more or less 
oedema, finally a high degree of dropsy. In the second case, 
the various phenomena of chronic uraemia result from the 



PRIMARY CHRONIC INTERSTITIAL NEPHRITIS. 211 



insufficient elimination of urinary solids. The patient, there- 
fore, faces a triple-headed Cerberus which may destroy him: 
(i) the cumulative action of toxins, (2) the weakening of the 
heart, and (3) the extension of the process in the kidneys. 

The arterial changes are progressive and the increased 
blood-pressure permanent. The hypertrophied muscular tissue 
is prone to degenerative changes, shows a greater tendency to 
exhaustion and weakness than the normal heart tissues, and 
it is but a question of time until increasing impairment of 
nutrition of the myocardium, with constantly growing peri- 
pheral resistance, results in failure of compensation and dila- 
tation of the hypertrophied ventricles. 

Diagnosis. — This is difficult to make from a few symptoms. 
Anders says: "A persistent albuminuria, together with pres- 
ence of casts in the urine and the passage daily of a large 
quantity of clear, pale urine of low specific gravity, is suffi- 
cient for diagnosis." 

The above is true enough, but the word "nightly" might 
with benefit be substituted for the word "daily." 

The writer's attempt at shortening the phraseology of the 
diagnosis is as follows: A patient, man of middle age, who 
voids unaccountably more urine at night than by day (in the ab- 
sence of pyuria), and who notices a loss of muscular strength, 
should be held to have chronic interstitial nephritis until, or 
unless, the contrary can be proved ; and the diagnosis is ren- 
dered more certain by the discovery of albuminuria, cylin- ' 
druria, and the signs of increased arterial tension. 

Onset. — It has been truthfully remarked that an albumin- 
uria coinciding with headache, dyspepsia and a tense pulse is 
always suspicious in a person over forty years of age. Add to 
this muscular weakness, which, in the writer's experience, is 
one of the earliest symptoms, and rising at night to void a 
copious amount of pale urine, and we have the cardinal feat- 
ures of the onset of this disease. 

Increased arterial tension is the most important of the early 
symptoms. 



212 CHRONIC DIFFUSE NEPHRITIS WITH INDURATION. 

The excess of night urine over day is sometimes extra- 
ordinary. In one of the writer's cases the patient voided 
eight times as much urine from eight at night to eight in the 
morning as during the next twelve hours. 

The onset presents usually some one or other of the follow- 
ing conditions : 

i. The disease is latent so far as subjective symptoms go, 
the first of which may be sudden and unexpected uraemia or 
apoplexy. 

2. The disease shows itself first by cardiac or vascular 
symptoms, dyspnoea, palpitation and slight oedema, or merely 
by increased pulse tension. 

3. The first symptoms may be nose-bleed or those of retin- 
itis. 

4. The first symptoms may be those of a general disturb- 
ance, loss of appetite, pallor and physical weakness. (Striim- 
pell). 

5. The writer finds quite commonly among the first symp- 
toms rising at night to urinate, the voiding of much pale, 
watery urine at night, and albuminuria, which, if absent at 
times, will usually appear after violent exercise, sexual ex- 
cesses or hearty eating of meat with wine drinking, as at 
banquets. In these cases there is almost always more or less 
muscular weakness. 

6. A congeries of symptoms may appear early, including 
headache, palpitation, bronchial cough, tinnitus aurium, 
muscae volitantes, dizziness, malaise, anorexia, etc., which if 
accompanied by an increase in pulse tension are significant. 

Whether albuminuria exists or not, insomnia, disorders of 
vision and digestive disturbances should direct attention to 
the kidneys, especially if the patient voids much pale- 
urine at night. Disturbances of the nervous system may be 
marked and appear early. The patient's disposition may 
change, and he may become morbidly depressed, peevish, 
suspicious, impatient or even suicidal. Certain cases in which 



PRIMARY CHRONIC INTERSTITIAL NEPHRITIS. 213 

peculiar variations in temperature suggest tuberculosis 01 
malaria, with weakness, pallor and night-sweats, have been 
noticed. 

Auditory troubles, vertigo, itching of the skin, muscular 
twitchings, cramps in the calves, especially at night, and sen- 
sitiveness to cold, especially of the lower limbs, are sometimes 
minor symptoms of the malady. 

According to Eichhorst suspicious symptoms include the 
following : Palpitation of the heart, persistent headache, im- 
paired vision, repeated epistaxis, persistent hoarseness, fre- 
quent vomiting, obstinate eczema, general itching of the skin. 
According to Anders, the disease may begin in seven different 
ways: 

i. It may not show evidences until late in life, when the 
kidneys are badly degenerated. 

2. It may show itself first through some complication or 
intercurrent malady as pneumonia or pericarditis. 

3. More commonly the first conspicuous evidence is an at- 
tack of uraemia followed by recovery with more or less im- 
paired health, and then another and severe attack which is 
either fatal or disabling. 

4. Spasmodic dyspnoea may be the first symptom. 

5. It may show itself by the gradual onset of periods of un- 
controllable drowsiness by day. 

6. The first evidence may be an attack of hemiplegia. 

7. Sometimes the case is one of progressive loss of flesh and 
strength with a dry, harsh, wrinkled skin, and finally death 
from sheer exhaustion. 

The writer thinks that the safest means of recognizing the 
disease early is careful study of the ratio of day urine to 
night in the case of men. An unaccountably large relative 
amount of night urine is always a suspicious sign if persistent. 
In the case of women this sign is, however, of much less 
value, as there are a number of conditions in which the 
amount of night urine is increased. 



214 CHRONIC DIFFUSE NEPHRITIS WITH INDURATION. 

Course and Duration. — The disease is an exceedingly irreg- 
ular one, and may remain stationary for years. Often its 
progression is by skips and jumps. It is possible that some 
patients with strong hearts and unimpaired digestion may 
resist it for twenty years. In the writer's experience, how- 
ever, it is uncommon for the patient to live more than seven 
or eight years after the diagnosis is rendered certain by the 
urinary features, viz.: Excess of night urine over day, defi- 
ciency of phosphoric acid, persistent presence of more or less 
albumin and a few casts. Intervals of several years of ap- 
parently good health are not at all uncommon. Cases in which 
albuminuric retinitis is established run a short course, seldom 
over three years, and usually less. In one case, however, 
which the writer saw, with Dr. J. H. Buffum, the patient 
lived more than five years after retinitis was found, and died 
from pyaemia following a carbuncle. 

Absence of albuminuria, which is claimed to be observed in 
some cases, may be, perhaps, due to the fact that the diseased 
glomeruli have wholly ceased secreting, and that the urine 
comes wholly from healthy ones only. Absence of oedema 
may be due to the fact that the heart is as yet able to do its 
work sufficiently to prevent retention of water in the system. 

There are a number of ways in which the disease may run 
its course ; not less than ten distinct ways are known. For 
clinical purposes we may divide the disease into three periods. 

I. Early Stage. — The patient may first complain of more 
or less weakness, insomnia, visual, digestive or auditory dis- 
turbances; he may be drowsy, and may have peculiarities of 
temperature. Although naturally of an amiable and sanguine 
disposition, he may become depressed, peevish, suspicious and 
impatient. No albumin as yet may be found in the urine, 
but the patient rises at night to urinate, and the night urine 
is paler and more copious than normal. Or there may be no 
features except slight muscular weakness and the nocturnal 
urination as above. 



PRIMARY CHRONIC INTERSTITIAL NEPHRITIS. 215 

II. Stage of Cardiac Hypertrophy. — In this stage the symp- 
toms are more pronounced, as follows : 

Symptoms of High Arterial Tension. — Slow, hard, cord-like 
radial pulse (62 per cent, of the cases). Throbbing temporals, 
headache, hemorrhages (nasal, cerebral, cutaneous, into retina). 
Retinal changes are said to be found in 25 per cent, of the 
cases, but in the author's experience they are usually found 
late in the course of the disease. 

Symptoms of Hypertrophy of the Left Ventricle. — Palpita- 
tion, displacement of apex beat downward and outward, 
increased strength of apex beat, increased area of cardiac 
dullness, especially to the left ; accentuation of the second 
sound in the second right costo-sternal interspace (80 per 
cent, of the cases). 

Headache, giddiness, tinnitus aurium, general congestion, 
oppression, dyspnoea without lung trouble apparent, asthmatic 
attacks, angina, shortness of breath on exertion, consciousness 
of violent beating of the heart. 

Note. — In this stage exposure or excess may bring on 
hemorrhages, acute uraemia, or inflammation of internal 
organs, as follows: Lobular pneumonia in 13 per cent, of the 
cases; pleurisy; pericarditis; bronchitis common, and persist- 
ent winter cough ; peritonitis rarely. 

Hypertrophy of the left ventricle without valvular disease is 
of the greatest importance in directing the attention to the 
kidneys in a doubtful case. It may be absent in weak, cach- 
ectic patients. 

Reduplication of the first sound is not uncommon, while 
the second sound as heard over the aortic area is accentuated 
and has a peculiar ringing quality. A systolic murmur heard 
at the apex and transmitted to the left may develop later. 

While the pulse is usually slow in the stage of cardiac 
hypertrophy, it may become rapid and unusually full and 
hard when extension of the process in the kidney renders 
even the most vigorous efforts of the heart insufficient to keep 



216 CHRONIC DIFFUSE NEPHRITIS WITH INDURATION. 

up sufficient urinary excretion. The first sound of the heart 
is usually, however, indistinct. 

Broadbent claims that one of the early indications of arterial 
pressure and changes in the blood-vessels and the heart is the 
reduplication of the first sound, best heard in the inner side of 
the apex. 

Use of the Sphygmograph. — This instrument, as Cabot 
says, is a fascinating little toy, but in the present form almost 
devoid of practical usefulness because almost any type of 
tracing can be obtained from the normal pulse by varying the 
pressure. 

Cerebral Hemorrhage. — In the stage of cardiac hypertrophy 
cerebral hemorrhage is not uncommon, occurring in perhaps 
1 6 per cent, of all the cases. South ey observed it in 45 per 
cent, of 358 cases, and in 111 deaths from apoplexy in St. 
George's Hospital chronic interstitial nephritis existed in 
fifty-five. 

Clinical Summary. — Clinically, however, we find in the 
stage of cardiac hypertrophy that the patient's subjective 
symptoms are chiefly headache, due to active cerebral hyper- 
semia ; vertigo, due to the same cause, and nose-bleed. 

The nutrition of the patient may not be greatly changed if 
the disease progresses gradually, and corpulence may be pres- 
ent. In younger patients only there may be pallor. 

In later stages, however, the patient is emaciated and of 
sallow, often cyanotic, complexion. 

The skin is sometimes affected. Samuel West has noted 
erythema, pityriasis, dermatitis exfoliativa, general eczema, 
a discrete papular eruption, sometimes lichenous, sometimes 
resembling chronic urticaria. 

The Urine in the Stage of Hypertrophy. — The features are 
polyuria, night urine equal to or more usually exceeding day, 
deficiency of urea, marked deficiency of phosphoric acid; 
albumin small, sometimes traces only, or absent; casts few, 
hyaline or absent. 



PRIMARY CHRONIC INTERSTITIAL NEPHRITIS. 



217 



Polyuria is not invariably present. On some days the urine 
may be sub-normal in quantity, but the general tendency is 
to void more urine than normal. 

Quantity in Twenty-four Hours. — Usually, in earlier stages, 
two or three times the amount normal for the patient, from 
2500 to 3000 c.c., 80 to 100 ounces at most. Occasionally 
4000 or 5000 c.c. are passed, especially if patient drinks 
freely. In one of the writer's cases the patient voided 5330 
c.c. of a specific gravity of 1.001. 

Urea. — Deficient, both relatively and absolutely. 

Phosphoric Acid. — Greatly decreased, relatively and abso- 
lutely. Characteristic. Ratio of urea to phosphoric acid 
may be above 12 to 1. 

Chlorides and Sulphates. — Decreased. Chlorides less than 
other constituents. 

Color. — Pale, transparent when fresh ; hazy at end of 
twenty-four hours. 

Specific Gravity. — Varies from 1.005 to i-oio, and seldom 
goes above 1.012 until stage of heart failure, when it may rise 
to 1. 018 or 1.020. The specific gravity of the day urine may 
be higher than that of the night. 

Albumin. — As a rule, small in quantity (less than one on 
Esbach tube, less than ten per cent, bulk by the ferrocyanic 
method in centrifugal machine, five minutes at 1000 revolu- 
tions per minute). In acute intercurrent attacks, ursemic 
attacks, or febrile attacks, increases. 

May be absent from night urine and present only in traces 
in day when heart not dilated. May perhaps be absent alto- 
gether at times, especially when not in last stage, and when 
the disease is of vascular origin, or when cardiac symptoms 
(not dilatation) predominate over renal ones. 

Casts. — Usually two or three hyaline casts, occasionally 
dotted with epithelia or with fine granules, are all that are 
noticed except during acute uraemic attacks. 

It is said that fatal uraemia may take place when the urine 



218 CHRONIC DIFFUSE NEPHRITIS WITH INDURATION. 

is free from albumin and of normal specific gravity, but the 
writer rarely finds albumin absent in this disease after exer- 
cise, sexual intercourse and banquets. It is frequently the 
case, however, that no albumin can be found in the urine 
voided on rising in the morning, hence the practice so common 
of testing only the morning urine should be deprecated. 

Stage of Cardiac Dilatation. — When dilatation succeeds 
and compensation fails, any or all the symptoms of chronic 
endocarditis or myocarditis may appear. 

Extension of cardiac dulness to the right, possibly systolic 
souffle at apex, pulse weaker, more frequent, irregular ; dysp- 
noea prevalent ; dropsy sets in, beginning at the feet, extend- 
ing upward, and perhaps involving abdominal cavity ; cirrhosis 
of the liver, sub-jaundiced hue of skin, haemorrhoids, obstinate 
diarrhoea, watery stools at night. CEdema of the lungs or 
larynx may be present. 

Nutrition affected and patient loses flesh, has dry, withered 
skin, hard, rigid hair, drawn features, sunken face, sub-normal 
temperature, loss of sexual desire and power. (In earliest 
stages sexual irritation and increased desire.) Anxiety and 
wakefulness at night are frequent. 

Chronic urcsmic symptoms now pronounced : Dyspnoea, 
often asthmatic ; gastro-intestinal symptoms ; nausea, vomit- 
ing, diarrhceal attacks ; cutaneous symptoms, intolerable itch- 
ing and burning of the skin, persistent eczema ; general 
muscular weakness, cramp, numbness, pricking of the skin. 

In this stage the dyspnoea is due partly to pulmonary con- 
gestion, diffuse bronchitis, pneumonia and hydrothorax. At- 
tacks of asthma may be due either to cardiac weakness or to 
uraemia, and are sometimes associated with signs of acute 
pulmonary oedema with expectoration of a large amount of 
foamy, serous sputum often tinged with blood. 

The tongue is generally coated. It may be red, dry and 
cracked, or moist and glazed, 01 covered with a brownish 
scum, or furred and foul. 



VARIOUS MANIFESTATIONS OF THE DISEASE. 219 

Failure of cardiac compensation in the late stage is often 
indicated by an unaccountable diminution in the quantity of 
urine before severe ursemic symptoms, as above. 

The Urine in the Last Stage. — Quantity may be, and usu- 
ally is, less than normal ; albumin may increase in quantity 
(to second mark on Esbach tube, 20 to 30 per cent, bulk 
ferrocyanic); casts more easily found, including a few granu- 
lar. The specific gravity is higher and the color darker than 
in other stages. 

In this last stage apathy and semi-torpidity of physical and 
mental powers occur. Coma is more likely to take place 
than convulsions. 

It must be carefully understood that the disease may not 
plainly show its progression, through the three stages above 
described. Patients may either die of acute uraemia before 
reaching the third stage, or their condition may not be 
suspected by subjective symptoms or ascertained before the 
last stage is reached. It is surprising how rapidly the third 
stage may progress to a fatal termination. The writer has 
seen cases in which the duration of this stage was apparently 
not three months, and prior to this time the patient was about 
his business as usual. 

VARIOUS MANIFESTATIONS OF THE DISEASE. 

These are uraemia, retinitis, internal hemorrhages, and in- 
flammations of internal organs. 

Acute Uraemia. — In acute ursemic attacks there may be 
giddiness, drowsiness, muscular twitchings, periodical con- 
vulsions or coma ; the perspiration may be sticky and urinous; 
there may be a strong odor of the urine in the breath and to 
the body. Violent headaches may be noticed of uraemic origin, 
partly dependent on passive cerebral hypersemia or arterial 
anaemia of the brain. These headaches not infrequently 
precede convulsions. 



220 CHRONIC DIFFUSE NEPHRITIS WITH INDURATION. 

Acute uraemic attacks may come on any time in the course 
of the disease and are sometimes the first subjective signs of it. 

Retinitis. — This may come on at any time in the course of 
the disease, in which it is more frequent than in any other 
renal lesion. It may appear very early in the disorder. It 
is said to occur in from 15 to 25 per cent, of all cases of chronic 
interstitial nephritis, but it is possible that it is more frequent 
even than these figures indicate. Milligan reports a case of 
chronic interstitial nephritis with retinitis in a boy of seven. 

The cardinal features of albuminuric retinitis are yellowish 
spots around the macula lutea and larger spots in the neighbor- 
hood of the optic papilla. In addition there is frequently 
also seen swelling of the optic papilla, retinal haemorrhage, 
venous hyperaemia, and tortuous veins. 

Internal Haemorrhages. — These are not so common as retin- 
itis, but are clinically important signs of the presence of 
the disorder. They are due either to increased arterial press- 
ure, as in elderly persons with arterio-sclerosis, or to abnormal 
weakness in the blood-vessels due to defective nutrition, as in 
younger patients. Haemorrhages into the brain causing mild 
or severe apoplectic attacks are most common ; the latter may 
pass off without much injury to the patient or may result in 
hemiplegia or in death. 

Haemorrhages in the inner surface of the dura mater (haema- 
toma) also occur. The most frequent haemorrhage is nose- 
bleed. It is sometimes stubborn and has been known to 
cause death. 

Besides these there may be haemorrhages in the skin, stom- 
ach, intestines, and lungs ; a sort of haemorrhagic diathesis 
may in some cases develop. 

Inflammations of Internal Organs. — These are usually 
present some time in the course of the disease, as in all renal 
lesions. Pneumonia is the most frequent and important; in 
some cases it is croupous, in some lobar, and in others the 
diffuse lobular pneumonia peculiar to nephritis. 



DIFFERENTIAL DIAGNOSIS. 221 

Inflammations of mucous membranes manifest themselves 
by chronic bronchitis, gastritis, gastric and intestinal catarrh 
partly due to congestion partly to irritation. 

Inflammation of serous membranes occur, as pleurisy and 
pericarditis. Inflammation of the skin may be manifest by 
presence of eczema. 

Differential Diagnosis. — Primary chronic interstitial neph- 
ritis must in the onset often be differentiated from an attack 
of dyspepsia, gastro-enteritis, bronchitis, or cerebral disease. 
The condition of the urine and the increased pulse tension 
are the cardinal points for differentiation. 

Chronic interstitial nephritis must be differentiated from 
various nervous diseases, among which are neurasthenia and 
chronic myelitis, since the condition of the urine of those 
diseases sometimes resembles that of chronic interstitial neph- 
ritis, a fact which seems to have been overlooked by our 
authors. The differential diagnosis from mild cases of neuras- 
thenia is difficult, but age of the patient and previous history 
of nervous prostrations may distinguish. Chronic myelitis 
may be distinguished by the symptoms paraplegia, anaesthesia, 
hyperesthesia, and the like. Chronic interstitial nephritis 
must be distinguished from certain cases of myocarditis, the 
urine, pulse and symptoms being alike when the patient with 
myocarditis is an alcoholist or suffers from hunger. A 
dilated and hypertrophied heart is, moreover, essentially in a 
condition of chronic myocarditis. History of high tension 
with loud second sound and symptoms of chronic uraemia 
serve to distinguish the two diseases, since weakness of the 
heart and feeble sounds are characteristic of myocarditis. 

Note. — In the stage of cardiac dilatation uraemic symptoms 
and the urine serve to distinguish chronic interstitial nephritis. 

When chronic nephritis and chronic myocarditis coexist, 
and both kidneys and heart are inadequate, it is difficult to 
decide which is the primary condition. 

Babcock lays stress on the following points : If hypertrophy 



222 CHRONIC DIFFUSE NEPHRITIS WITH INDURATION. 

and dilatation affect the whole heart, if pulse tension is high 
and sustained out of proportion to the degree of cardiac feeble- 
ness and of peripheral arterio-sclerosis, and if the urine is 
scanty and deficient in solids with or without albumin, the 
renal disease is probably the primary or predominant one. 
If, on the other hand, cardiac enlargement is chiefly in the 
left heart ; if the peripheral vessels show marked sclerosis ; 
if the pulse tension is low ; if the urine, scanty in amount, is 
of high specific gravity with or without albumin, the condi- 
tion of the heart is more serious and threatening than that of 
the kidneys. 

It must be remembered that chronic interstitial nephritis is 
a disease in which certainty as to the diagnosis is to be had 
almost wholly from examination of the urine alone. If albu- 
min is not present, there will be difficulty in distinguishing it 
from myocarditis, idiopathic hypertrophy of the heart and 
certain cases of intestinal auto-intoxication, the latter quite 
common among constipated women. The presence of albu- 
minuria after exercise, sexual intercourse and banquets is, in 
the writer's experience, a help in the diagnosis. 

Primary chronic interstitial nephritis may be distinguished 
from secondary by the history of the case and the age of the 
patient. In secondary chronic interstitial nephritis the pa- 
tient is usually between twenty and forty years of age, and 
has a history of previous chronic diffuse nephritis without in. 
duration. In primary chronic interstitial nephritis the patient 
is usually over forty years of age, and lacks history of previous 
chronic diffuse nephritis without induration. A previous 
history of good health is quite commonly found in primary 
chronic interstitial nephritis, but never in secondary. More- 
over, in the secondary disease the urine is abundantly albu- 
minous, and the sediment contains blood corpuscles and 
numerous casts, mostly hyaline and granular, together with 
fatty epithelia. 

Chronic interstitial nephritis must be differentiated from 
hysterical polyuria. The urine in the former disease keeps its 



DIFFERENTIAL DIAGNOSIS. 



223 



low specific gravity in spite of decrease of daily quantity 
below the average normal. 

Primary chronic interstitial nephritis is distinguished from 
chronic diffuse nephritis without induration by the absence of 
general dropsy till late, the small quantity of albumin, and 
the few casts. 

The large amount of albumin and rareness of uraemia serve 
to distinguish lardaceous (amyloid) disease from chronic in- 
terstitial nephritis. 

In senile atrophy of the kidney and atrophy due to chronic 
endocarditis we find urine similar to that of chronic intersti- 
tial nephritis. The diagnosis rests upon the progressive 
development found in chronic interstitial disease, and the 
probability that in the other cases albumin and casts have 
been found for many years in individuals seemingly in good 
health. 

Chronic interstitial nephritis must be differentiated from 
diabetes insipidus. In the latter disease a trace of albumin 
may be found in the urine, together with polyuria and defi- 
ciency of solids ; but the polyuria is usually excessive, no 
casts occur, and the cardio-vascular and uraemic symptoms of 
chronic interstitial nephritis are absent. 

The differentiation of passive congestion of the kidneys from 
chronic interstitial nephritis is of importance. The following 
will be of help in the diagnosis : 



the urine; of 



Chronic Renal Hyperemia. 

Oliguria. 

Percentage of solids (grains 

ounce) increased. 
Color increased. 
Albumin small. 
Casts few, hyaline. 
Urates and uric acid in sediment. 

Blood corpuscles in sediment. 



Primary Chronic Interstitial 
Nephritis. 
Polyuria, 
per Percentage of solids decreased. 

Color decreased. 

Albumin small. 

Casts few, h3 7 aline. 

No crystalline sediment except a few 

oxalate crystals. 
, No blood corpuscles, unless cystic 

disease. 



224 CHRONIC DIFFUSE NEPHRITIS WITH INDURATION. 

SYMPTOMS OF 

Chronic Renal Hyperemia. Chronic Interstitial Nephritis. 

Valvular diseases without hyper- Hypertrophy without valvular dis- 

trophy. eases. 

Weak, thready pulse. Full, hard pulse. 

Dropsy, hydrothorax, etc. No dropsy till late. 

No uraemia. Chronic uraemia. 

No rising at night to urinate. Rising at night. 

No visual disorders. Visual disorders. 

In the stage of cardiac dilatation the comparatively light 
color of the urine and deficiency of solids with increase in 
albumin serve to distinguish from passive renal hypersemia, 
in which oliguria is accompanied by urine of deeper color 
with higher percentage of solids, but with a small quantity 
of albumin. 

It must be admitted, however, that there is sometimes con- 
siderable difficulty in differentiating. In the writer's experience, 
if the patient is not under the influence of diuretics, the scanty 
urine in passive hypersemia is usually 1.025 in specific gravity 
or higher, and the color red or even darker ; a deposit of urates 
is more common also in hypersemia than in contracted kidney 
in the stage of cardiac dilatation. Casts are somewhat more 
plentiful also in the renal cases than in the cardiac ones, and 
the percentage of urea not usually above 25 gm. per liter, 
while -in cardiac cases it may rise to 30 gm. or more per liter. 

The history of the patient is often serviceable in the differ- 
ential diagnosis. If the patient has had in the past the habit 
of voiding a relatively large amount of pale urine at night, 
and if there have been ursemic symptoms, especially transi- 
tory visual ones or more or less persistent auditory ones, the 
chances favor the diagnosis of renal disease rather than 
cardiac. There is in the renal cases also a general tendency 
toward abnormally loud aortic second sound of the heart. 
Moreover, the case is far less amenable to treatment when 
renal than when cardiac, as the physician will soon find out 
after a week or two of trial. 



DIFFERENTIAL DIAGNOSIS. 225 

When chronic interstitial nephritis is first seen during 
sudden ursemic or apoplectic attacks, it may be extremely 
difficult to distinguish it from acute cerebral disorders. 

Chronic interstitial nephritis must be differentiated from 
auto-intoxication of intestinal origin, especially in consti- 
pated women. The following paper by the author will help 
in the diagnosis : 

One of the questions which frequently comes up is whether 
the patient has contracting kidney or simply auto-intoxication 
of intestinal origin. In the case of men, it is seldom that the 
answer cannot be soon given ; but when the patient is a 
woman, greater difficulty is experienced in solving the prob- 
lem. Take, for example, a case like the following, one of 
many which the writer has seen : 

Patient a woman, 45 years of age. Urine in twenty-four 
hours, 72 fl. oz.; night urine exceeds day; specific gravity, 
1.009 ; reaction neutral ; urea per twenty-four hours, 150 
grains ; phosphoric acid, 24 grains ; uric acid, 3 x / 2 grains ; no 
albumin ; no sugar ; sediment of the usual epithelia ; no casts ; 
no crystals ; no pus ; no blood ; no connective tissue. 

More than one such case has been referred to the writer 
with the diagnosis of contracting kidney already made by the 
attending physician. Now, it is true that in contracting 
kidney we find urine of such quantitative composition ; but, in 
the writer's experience, if the urine voided at different times 
in the twenty-four hours be carefully examined, either a trace 
of albumin or several hyaline casts per 15 c.c. of urine, or 
both, will be found, if it is really a case of contracting kidney. 
In the case above described no albumin and no casts could be 
found at any time of day. Furthermore, if no albumin or 
casts can be found after the patient has eaten as heartily as 
possible of meat, and has also been subjected to the test of as 
severe exercise as advisable, then the presence of contracting 
kidney becomes improbable, especially if cardio-vascular and 
retinal changes are absent. 

15 



226 CHRONIC DIFFUSE NEPHRITIS WITH INDURATION. 

It will not be out of place here for the writer to inveigh 
against the too frequent practice of testing only the urine 
voided on rising in the morning. If the patient is merely 
told to bring a sample of urine for examination without 
further directions, the chances are very great that he, and 
especially she, will bring the urine voided on rising in the 
morning, which, even in well-advanced cases of contracting 
kidney, may contain neither albumin nor casts. A classical 
case of this kind the writer once saw with Dr. C. G. Fellows. 
After Dr. Fellows had made the diagnosis of retinitis albu- 
minurica, and after careful examinations of the twenty-four 
hours' urine had shown the qualitative and quantitative indi- 
cations of contracting kidney, the writer examined the urine 
voided on rising in the morning, and found nothing but a 
urine of poor quality, without either albumin or casts, and 
this, too, but a few weeks before death from typical uraemia. 
Mild, slow cases of contracting kidney are to be found in 
which albumin and casts may be absent in the forenoon. 
Such patients may in the earlier stages be accepted by life 
insurance examiners whose hours are early in the day. But 
the writer has yet to see a case of contracting kidney, or one 
which in a few months, at any rate, has developed into a 
recognizable case of contracting kidney, in which albumin or 
casts could not be found at some time in the day, especially 
after exercise or after hearty eating of meat. In men whose 
cases are at all doubtful it is the writer's habit to request the 
urine for examination to be collected during the twenty-four 
hours following a " stag " dinner or banquet. Any doubts 
about the case can usually be set at rest by examination of 
urine thus collected. The same may be said of urine voided 
after excessive sexual intercourse, with the observation, how- 
ever, that such urine in the case of young men may contain 
albumin in small quantity (without casts or other evidences 
of renal lesion), probably referable merely to temporary renal 
congestion. 



DIFFERENTIAL DIAGNOSIS. 227 

But to return to the case of women. Here the condition is 
more puzzling. We find women with impaired health, unable 
to attend to their usual duties, occupations, or pleasures, on 
the verge of nervous prostration, collapsing entirely in hot, 
humid weather, voiding a relatively great quantity of pale urine 
at night, and not excreting 200 grains of urea in all during 
the twenty-four hours. Most careful examination of the urine 
fails to discover either albumin or casts at any time of day. 
Let it be understood, however, that the so-called delicate tests 
for albumin are excluded. The writer has shown, in an article 
in the New York Medical Times, that several of these tests 
(Spiegler's and the trichloracetic especially) are subject to 
grave error from presence of alkaline carbonates. Now, it is 
in just such urine as that voided by women described above 
that we can find a white ring with some of these delicate 
tests, due to presence of these same alkaline carbonates. Add 
to such urine 10 per cent, of its volume of an 8c per cent, 
solution of calcium chlorid (pure crystals), filter, test again, 
and there is no white ring to be found, because calcium car- 
bonate has been precipitated and filtered off, and albumin is 
absent. When the writer refers to absence of albumin, it is 
understood that boiling, followed by cautious addition of acetic 
acid (50 per cent.) drop by drop, shows no readily perceptible 
haze, and the cold nitric acid test performed by means of the 
albumoscope shows no white ring at all at the juncture of the 
fluids against the black background. 

Moreover, repeated microscopical examinations of the urin- 
ary sediment, with and without centrifugal sedimentation, 
reveal no casts, or, at most, not more than one small hyaline 
cast, occasionally found. 

. When such results are obtained by examination of the urine, 
and when evidences of cardio-vascular changes or retinal 
changes are absent and typical uraemic manifestations are 
lacking, how can we make a diagnosis of contracting kidney ? 

On the other hand, it is true that contracting kidney is a 



228 CHRONIC DIFFUSE NEPHRITIS WITH INDURATION. 

most mysterious and insidious malady, and that it requires no 
small courage to deny its existence in the case of any obscure 
ailment in a person over fort)' years of age. The writer, how- 
ever, believes that in the case of women this lesion is not 
common. Hundreds of women with urine like that of the 
analysis described in the beginning of this article have pre- 
sented themselves from time to time for examination, and the 
writer is unable to recall a single case in which subsequent 
developments have shown indubitable proof of the presence 
of chronic renal lesion. Even supposing that a dozen of them 
have died of uraemia, unknown to the writer, this would be a 
small proportion compared with the number which the writer 
positively knows to be alive and still devoid of any tangible 
evidences of contracting kidney after a period of several years. 
There is no question whatever, so far as the writer's experi- 
ence goes, that contracting kidney is as uncommon in women 
as it is common in men. 

On the other hand, the frequency of ovarian and uterine 
diseases, constipation and fecal impaction, in the case of 
women, have much to do with the development of what used 
to be called "renal insufficiency." The observations of Lucas- 
Championniere on the influence of ovarian diseases on the ex- 
cretion of urea in women have already been quoted by the 
writer ("Manual of Urinary Analysis," 3d Ed., page 82). The 
effect of fecal impaction on the urine is well shown by the 
following case : Patient, a woman, 43 years old, on the verge 
of nervous prostration, without organic lesion so far as could 
be discovered. Examination of the urine revealed the follow- 
ing : 

Total urine for 24 hours, 34 fl. oz.; night urine, 22 fl. oz.; 
day urine, 12 fl. oz.; specific gravity, 1.014 ; total urea, 177 
grains; total phosphoric acid, 19 grains; total uric acid, 1 
grain ; no albumin ; no sugar. 

Sediment : The usual vaginal epithelia ; no casts ; no crys- 
tals ; no pus ; no blood. 



DIFFERExNTIAL DIAGNOSIS. 229 

No albumin and no casts could be found in the urine of 
this patient at any time of day. Cardio-vascular and retinal 
changes were ab c ent. Her extreme weakness, however, and 
tendency to collapse in hot, humid weather bespoke some 
kind of toxaemia. 

. The writer refused to make a diagnosis of contracting kid- 
ney, and ordered vigorous colon flushing, which was most 
conscientiously done, and repeated until an immense mass of 
impacted feces was removed. Now, what was the result? 
After the colon flushing was over, examination of the 2\ 
hours' urine showed the following changes : 

Total urine, 26 fl. oz.; day urine, 16 fl. oz.; night urine, 10 
fl. oz.; specific gravity, 1.015 ; urea, 279 grains; phosphoric 
acid, 32 grains ; uric acid, 1 grain. Otherwise as above. 

This is not the first time the writer has seen a re-establish- 
ment of the normal excess of day urine over night and an in- 
crease in urea follow colon flushing and removal of impacted 
feces. The patient is still alive, fairly well, and shows no 
signs of contracting kidney. Further examinations of the 
urine show neither qualitative nor quantitative deviations 
from normal worth noticing. The last analysis, one year 
after the discovery and removal of the fecal impaction, showed 
three hundred grains of urea in the twenty-four hours' urine- 

In answer, then, to the question, Have we a case of con- 
tracting kidney, or not? the writer submits the following con- 
clusions : 

1. In the case of men over forty voiding urine of poor qual- 
ity, with night urine exceeding day, the presence of contract- 
ing kidney is exceedingly probable ; and urine voided after 
banquets, exercise, or sexual intercourse, is likely to confirm 
the probability by showing presence of albumin and casts. 
L,ater the presence of cardio-vascular or retinal changes con- 
firms the diagnosis, in case these are absent in the beginning. 

2. In the case of women over forty voiding urine of poor 
quality, even if the night urine exceeds the day, the presence 



230 CHRONIC DIFFUSE NEPHRITIS WITH INDURATION. 

of contracting kidney is improbable if, as is so often the case, 
neither albumin nor casts can be found at any time of day — 
especially improbable if ovarian and uterine diseases are pres- 
ent, and where milk diet increases urea to normal. Contract- 
ing kidney can probably be excluded by the return of the 
urine to permanent normal quantitative conditions after flush- 
ing of the colon and removal of impacted feces, when also, of 
course, cardio-vascular or retinal changes are not to be found. 
(The Hahnernannian, January, 1902.) 

On the other hand, it cannot be denied that gastro-intestinal 
disturbances, and especially chronic constipation, by imposing 
greater work on the liver, may be a fruitful cause of irritation 
of the kidney, and that, if the kidney is already diseased, these 
conditions undoubtedly aggravate the renal trouble. 

Prognosis. — The disease is incurable, but may be subject to 
long periods of remission. If symptoms are of chronic uraemia 
(headache, dyspepsia, visual disturbances), without cardiac 
weakening, disease may be checked for years by diet and 
medication — in extreme cases twenty years. Suitable climate 
may help. After the heart begins to fail, life is usually pro- 
longed not more than a few years at most. After marked 
cardiac dilatation takes place it is a question, as a rule, of 
months, or even weeks. 

Death sometimes occurs unexpectedly in earlier stages, when 
the patient is apparently enjoying a remission, from sudden 
cerebral haemorrhage or acute uraemia, or more gradually 
from acute inflammation of serous membranes, lungs, or in- 
testines. 

Convulsions and apoplectic seizures are often fatal ; unfa- 
vorable signs are persistent vomiting and diarrhoea, retinitis, 
delirium and coma. 

Dangers. — The chief dangers in the course of the disease 
are acute nraemic attacks and haemorrhages. Both may take 
place at almost any time, but haemorrhages within the retina, 
brain or internal organs are rather more common after cardiac 
hypertrophy is established. 



TREATMENT OF CHRONIC INTERSTITIAL NEPHRITIS. 231 

Excesses, over-exertion, or exposure may be followed by 
pneumonia, dysentery, acute uraemia, pleurisy, oedema of the 
lungs and peritonitis, the latter less commonly. It is doubt- 
ful whether endocarditis is a consequence of the disease. In 
the stage of cardiac dilatation, uraemia, heart-failure and ex- 
haustion are the chief dangers ; the patient may also succumb 
to secondary pneumonia, which, in this stage, may prove rap- 
idly fatal. 

Among other dangers frequently noticed by the author is 
that from accident, the result of vertigo. The patient may 
be badly injured as a result of a fall when seized with vertigo. 
In one of the writer's cases death soon followed concussion of 
the brain from such a cause. 

Pericarditis is a grave complication ; it may produce no 
symptoms and only be discovered accidentally when the fric- 
tion sounds are heard. 

THE TREATMENT OF CHRONIC INTERSTITIAL 
NEPHRITIS. 

Modern writers are agreed that the disorder is essentially 
incurable, hence the necessity of prophylaxis. 

Prophylaxis. — Avoidance of meat and highly-seasoned 
foods and rich gravies, regular ingestion of fluids, avoidance 
of alcoholic beverages, malarial localities, and irregular modes 
of life. 

Overworked men and indolent, luxurious women should 
form the Turkish-bath habit in early middle life, especially if 
of gouty ancestry, but chilling after the bath is said to be a 
frequent cause of this disease. 

Climatology as in chronic diffuse nephritis without indura- 
tion. 

The writer suggests that instead of taking Turkish baths 
in the summer time, the patient visit the mud-baths. 

Principles of Treatment. — These are first to guard the 
kidneys against all sources of irritation, and, second, to lessen 



232 CHRONIC DIFFUSE NEPHRITIS WITH INDURATION. 

the strain on the heart. The first is accomplished, so far as 
possible, by diet and great care of the skin and bowels, the 
second by avoidance of over-exertion, excess, mental strain, 
together with moderate, methodical exercise, especially for 
the corpulent. 

The conditions which confront us are thickened and in- 
elastic arteries, which are constantly subjected to the strain of 
a heightened tension, and a hypertrophied and sensitive heart 
muscle. Thus the patient is exposed to the risk of rupture 
of the degenerated vessels on the one hand, and failure of 
the hypertrophied heart on the other. 

Regimen. — Woolens next to the skin at all seasons of the 
year, and special care to avoid exposure and over-exertion or 
excess. Systematic out-door exercise graduated to the strength 
and habits of the patient, hence out-door life in a mild, 
equable climate, like Southern California, of the utmost benefit. 
Skin and bowels to be attended to. Warm clothing and 
frequent warm baths, with care to avoid subsequent chilling. 
During stage of cardiac hypertrophy patient must be particu- 
larly cautious about running or over-exertion. 

Warm baths or salt baths with daily sponging of the whole 
body with brandy or vinegar are helpful. 

When the heart begins to fail rest is necessary, but massage 
and passive movements may help prevent impairment of nutri- 
tion. 

Climatology. — Patients may derive benefit from sea voy- 
ages, residence in Southern California, Southern Europe, or' 
near the African desert, as at Helouan. But in the last stage 
of cardiac dilatation, or where for any reason the end seems 
near, keep the patient at home where he can be made comfort- 
able and receive the attention of his friends and family. 

Diet. — Owing to the long continuance of the disorder milk 
diet is not possible, nor is it useful except perhaps during 
acute intercurrent attacks, when Vichy and milk are useful. 
Alcoholic drinks are forbidden, especially beer and cham. 



DIET ADD CHRONIC INTERSTITIAL NEPHRITIS. 233 

pagne. The diet should be farinaceous as far as possible, 
with sufficient fish, chicken, and occasional meat to keep up 
the strength. The patient should drink sufficiently of liquids 
to keep the urine a little above three pints daily ; but when 
there is already polyuria, it is doubtful whether copious inges- 
tion of mineral waters is of value. 

During stage of heart failure diet should be more liberal 
and a little meat allowed daily. 

The theoretical allowance of meat is five ounces daily. 
The following paper by the author may be serviceable in the 
treatment of the disease : 

DIET AND CHRONIC INTERSTITIAL NEPHRITIS. 

In those who have no obstruction to the free flow of urine 
the foremost cause of chronic interstitial nephritis is now 
thought to be long-continued irritation of the kidneys from 
the passage through them of the products of imperfectly 
digested food. The disease is notoriously common among 
those who "live well," as the expression is. Inasmuch as 
those who " live well " consume a great deal of meat, we have 
concluded that it is the meat which is the cause of the neph- 
ritis. But if those who " live well " be watched carefully, it 
will be observed that in addition to eating meat they eat and 
drink a good many other things. And after they have eaten 
too much meat plus too many other things they depress the 
nervous system by smoking strong cigars, by late hours, busi- 
ness tension or worry, or excessive venery. Now, it is ad- 
mitted, I believe, that it is harder to digest meat when at the 
same time sugars and starches are eaten freely. The person 
may be able to manage the sugars and starches without an 
attack of " indigestion," but at the expense of imperfect diges- 
tion of the meat. This may possibly explain why it is that 
persons who boast that they have always been able to digest 
"anything" finally succumb to contracting kidney. 

The kidneys in such cases have suffered in silence, as is 



234 CHRONIC DIFFUSE NEPHRITIS WITH INDURATION. 

their wont, for years. Proof of the innoxious character of 
nitrogenous food alone without sugars and starches is to be 
had from observation of diabetics in whom, as a rule, nitroge- 
nous diet fails to produce chronic interstitial nephritis. We 
must reason, therefore, that it is not the eating of meat alone 
which causes contracting kidney, but the imperfect digestion 
of it from various causes coupled with imperfect elimination 
from various other causes. 

A healthy man may eat a pound or two of beef in a day 
with impunity, regardless of the theoretical inability of the 
kidneys to dispose of the waste matter if, at the same time, he 
looks after the ventilation of his rooms, sleeps his healthy 
quota of hours, drinks water only and that in plenty, exercises 
moderately in the fresh air, avoids sweets and excess of 
starches, and does not depress his nervous system by excessive 
smoking, worry or venery. That this is not an idle statement 
may be proved by the writer's own experience of fifteen years 
or more of beef eating, three times daily, with not an hour 
missed from his profession because of illness during the entire 
period nor a single attack of headache. On the other hand, 
a single so-called " banquet " of a dozen courses of more or 
less indigestible food, including a good deal of meat, the 
smoking of several cigars, and the drinking of various wines, 
may immediately give rise to all the phenomena so clearly 
described by Dr. Haig, in his interesting book on Uric Acid. 
Or if the eating of meat be coupled with the drinking of beer 
similar ill-effects may be noticed. Chilling of the surface of 
the body under such circumstances leads to repeated conges- 
tions of the kidneys, and is undoubtedly a factor of import- 
ance in the etiology of contracting kidney, a disease of the 
temperate zone in localities where sudden changes in the 
weather are common. 

The question of what happens to the kidneys of those who 
eat more meat than the theoretical allowance of five ounces 
may be answered as follows : If the eating of meat be properly 



DIET AND CHRONIC INTERSTITIAL NEPHRITIS. 235 

conducted without the concomitants mentioned above, fifty 
ounces of urine in the twenty-four hours will contain five 
hundred grains or more of urea and ten grains, or even more, 
of uric acid, and the kidneys be none the worse for it. If, on 
the other hand, the eating of meat be improperly conducted, 
the amount of urea may be large enough, but the quantity of 
uric acid will fluctuate widely, a trace of albumin appears, 
sooner or later becoming two to five .per cent, bulk, and 
which, after "banquets," is especially noticeable. The indi- 
vidual in the latter case first notices loss of muscular strength, 
and then headaches or persistent neuralgias. Later he has 
either acute ursemic attacks or the cardiac and vascular symp- 
toms now so well recognized as phenomena of chronic inter- 
stitial nephritis. 

The dietetic prophylaxis of contracting kidney then nar- 
rows down from a practical standpoint to limitation of the 
amount of meat ingested, or to care not to overload the stom- 
ach with sweets and starches in the case of individuals who 
eat meat freely. It is difficult, not to say impossible, to con- 
vince the average layman in good health that he is eating 
anything which in time may kill him. He is, however, more 
or less open to conviction along the line of moderation. It 
often happens that owing to the wretched cookery, unfortu- 
nately almost universal in the United States, meat is about 
the only dish upon which a man doing brain-work can nour- 
ish himself. It is idle, therefore, to expect a person at the 
mercy of a Swede servant girl to starve himself to death in 
order to avoid the remote contingency of contracting kidney. 
But if physicians would insist that a person obliged to live 
largely on meat should avoid sweets and excess of starches 
and drink plenty of water, some practical good might be ac- 
complished. 

When once the disease has become established the problem 
of diet is serious. In cases where headaches are severe the 
writer appears to have demonstrated that there is a relation- 



236 CHRONIC DIFFUSE NEPHRITIS WITH INDURATION. 

ship between meat-eating and the headaches, and believes that 
no meat at all should be allowed patients subject to severe 
attacks of cephalalgia. In other cases the amount of meat to 
be allowed can in general be guessed at by the amount of 
albumin in the urine and the symptoms of the patient. For 
example, the writer recalls one case in which the amount of 
albumin, for some time merely a trace, rose to two per cent, 
bulk during the twenty-four hours following hearty eating of 
beefsteak at dinner. Milk as a steady diet in chronic inter- 
stitial nephritis is not to be thought of, as it fails to nourish 
the patient properly. On the other hand, buttermilk, made 
from good whey, is probably of great value as an addition to 
the diet. The writer thinks that not enough attention has 
been paid to buttermilk as an article of diet in contracting 
kidney. The patient who lived the longest of any under the 
writer's observation subsisted almost wholly for years on but- 
termilk. This same patient broke his oculist's record for 
length of time of survival after onset of albuminuric retinitis, 
and, although he finally died, the cause of death was pyaemia 
from carbuncle. Other articles of diet usually allowable are 
oysters, fish, sweetbreads, bread and butter, cereals, and not 
too acid fruits. Chicken should be fresh-killed and well- 
cooked. In the writer's experience nothing is more common 
on the tables of Americans than tough chicken, and it is ex- 
ceedingly doubtful whether as such it is allowable. When 
meat in small quantity appears to do no harm, a small, ten- 
der, well-cooked mutton-chop is the desideratum ; the leath- 
ery article usually in evidence is not to be thought of. Beans 
and peas are not only nitrogenous, but flatulent, and should 
be forbidden. An excellent dessert is baked apple, especially 
in the case of those inclined to constipation. Those who can- 
not eat apples on account of difficulty in digesting them 
should have them baked for not less than three hours, until 
they are almost a jelly. The action of them even then on 
the bowels is marked. In the matter of fruits, such as grapes 



DIET AND CHRONIC INTERSTITIAL NEPHRITIS. 237 

and peaches, too much care cannot be exercised in selecting 
ripe ones. 

In fact, the question of diet is, in the writer's opinion, quite 
as much one of how the patient's food is selected and cooked 
as it is one of what he eats. Poor cookery kills more Ameri- 
cans in the long run than almost anything. Without wish- 
ing to disparage the value of time spent in the study of bac- 
terial diseases the writer regrets that an equal amount of time 
is not given to the study of diseases which may be prevented 
by closer attention to the selection and cooking of ordinary 
food. 

In general, the diet should consist of lean meat once daily, 
the remainder of the diet consisting of vegetables, green fruits, 
light farinaceous foods and Battle Creek foods. Tea, coffee, 
cocoa and the natural mineral waters are allowed. During 
attacks of indigestion, milk is the proper diet ; buttermilk, 
koumyss or matzoon may also be serviceable then. Patients 
whose digestion is weak should take digestive powders after 
meals, and perhaps bitter tonics before meals. 

Harmful Effects of Drugs. — During the stage of cardiac 
hypertrophy certain crude drugs may do harm ; for example, 
iron and digitalis in massive doses should not be given, espe- 
cially when there is high arterial tension. 

Morphine has undoubtedly killed many a patient with con- 
tracting kidney. The indiscriminate practice of giving hypo- 
dermics of morphine and repeating them the same day can not 
be too strongly condemned in the treatment of this disease. 

The patient with contracting kidney frequently has in- 
somnia, and in routine practice a quarter of a grain of mor- 
phine sulphate is often given hypodermically. This may do 
no harm, but another one of increased dose, the same night, is 
dangerous, and in one case the writer knows of was apparently 
the cause of death, as the patient failed to awaken the next 
morning. We do not hear so much about these fatal cases as 
about those in which some therapeutic agent is reported to do 



238 CHRONIC DIFFUSE NEPHRITIS WITH INDURATION. 

good. Opium and morphine are known to have a cumulative 
action in contracting kidneys, and when needed should be 
given in single, not repeated, doses. 

Herter calls attention to the fact that a single grain of 
methylene blue may precipitate uraemia when the latter is im- 
pending. Nitroglycerine and the nitrites in large doses are 
also said to be dangerous when acute uraemia threatens the 
patient. 

Mercury in large doses should not be given in cases of con- 
tracting kidney of gouty or rheumatic origin, nor in those due 
to lead poisoning. 

In chronic interstitial nephritis the writer has observed in 
several cases stomatitis follow the use of calomel as a purga- 
tive agent. 

Symptomatic Treatment. — The usual remedies are Aconite, 
Arsenicum, Aurum muriaticum, G-lonoin, Kali iodatum, 
Iodine, Lithium carb. or benz., Mercurius cor., Nitric acid, 
Nux vomica, Plumbum metallicum, Phosphoric acid. 

The writer has seldom seen much lasting benefit from any 
of these, yet at times they appear to relieve certain symp- 
toms, especially Aurum muriaticum, Glonoin and Lithium 
benzoate. 

Aconite. — In the writer's experience io-drop doses of the 
second decimal dilution of Aconite have been effective in con- 
trolling the feeling of " rush of blood to the head " which 
patients sometimes complain of in this disorder. 

It may also be used in alternation with Glonoin when in 
connection with the above there is dizziness or vertigo. 

Aurum mur. — Cardiac palpitation, pressing pain, or feeling 
of heat in the lumbar region extending to the bladder and 
down the sides ; hyperesthesia and over-sensitiveness to pain ; 
general weakness, gastric and hepatic disturbances ; patient 
hypochondriac and quarrelsome. 

The leading indication for Aurum is the passage of much 
clear, pale, slightly albuminous urine at night so characteristic 



TREATMENT OF CHRONIC INTERSTITIAL NEPHRITIS. 239 

of interstitial nephritis. The writer uses the Chloride of Gold 
and Sodium in doses of from Tiioth to ^th of a grain four 
times daily. A one per cent, solution of this substance in 
alcohol may be made, of which ten drops, four times daily, is 
the dose. It certainly relieves the nocturnal urination in 
some cases. 

Glonoin. — This remedy is much used in conditions where 
there is high tension. In cases not urgent it should be given 
in doses of ^~oth grain every two hours for long periods ; alter- 
nation every third week with Caffeine, two grains every three 
hours, is sometimes desirable. For the acute blinding head- 
aches it should be given in larger doses, but it has failed to 
relieve even in enormous doses. When apoplexy threatens, 
use instead Sodium nitrite in full doses, three grains every 
four or five hours, together with venesection and saline in- 
fusion as recommended by Dr. Carter. 

The indications for Glonoin are polyuria, urine of low 
specific gravity, violent heart action, great arterial tension, 
heart's action easily excited, violent palpitation, throbbing 
carotids, pulsating headache, worse on stooping ; purring noise 
in the heart when lying down, arrythmic pulse, restlessness 
in the limbs, painless throbbing in all parts of the body, face 
bright red, puffy, cerebral hypersemia. Its action is marked 
in arterial tension, ursemic headaches and asthma. 

The therapeutic application of Glonoin and the Nitrites is 
also seen in angina pectoris, ursemic asthma and in the 
various high tension disturbances of primary chronic intersti- 
tial nephritis, as well as in arterio-sclerosis. Amyl nitrite acts 
more promptly than Glonoin, but its action is less prolonged. 

Erythrol tetranitrite is said to produce effects lasting six 
hours without affecting the head unpleasantly. 

The Iodides. — The indications for Iodine or Iodide of potas- 
sium are frequent desire to pass urine with profuse discharge, 
eructation, dry skin and cardiac hypertrophy. There are 
darting pains in the region of the kidneys, burning pains in 



240 CHRONIC DIFFUSE NEPHRITIS WITH INDURATION. 

the lumbar region, difficulty in walking ; the urine is clear 
and copious, especially at night, and of low specific gravity. 
(Compare Aurum muriaticum.) Use the first decimal except 
in syphilitic cases. The Iodide of sodium may also be given 
in the first decimal, or in one or two grain doses of the crude 
in water three or four times daily after meals. 

In syphilitic cases give Merc, cor., second decimal, and 
Potassium iodide, 5 to 10 grains, in water after meals alter- 
nately three times daily. A convenient way to give the Iodide 
is to dissolve seventy-five grains in six and one-half ounces of 
water ; dose, one tablespoonful after each meal. 

H. B. Millard, for routine treatment of chronic interstitial 
nephritis, placed the patient on full doses of Potassium iodide, 
and in addition gave Fowler's solution and Mercurius corro- 
sivus. 

Mercurial inunctions may be substituted for Merc, cor., and 
in obstinate cases the Protoiodide of mercury in one-quarter 
grain doses or more of the crude is often very serviceable. 

The Iodide of strontium is frequently better suited to cases 
of interstitial nephritis with pronounced cardiac symptoms 
than the other iodides. Anaemic cases may require the iodide 
of iron. 

If the patient is of bilious habit with coated tongue and 
sluggish liver the Protoiodide of mercury may be given for a 
few days. 

The preparation known as Soluble Iodine and the Syrup of 
Hydriodic acid are also used instead of the various iodides. 

Mercurius corrosivus. — This remedy in the third decimal 
trituration is used extensively in the routine treatment of con- 
tracting kidney, especially where there is retinitis. The 
writer can not report any very great success from use of it. 
Dr. Speirs Alexander records a well-marked case in which 
defective vision improved, power of accommodation returned, 
and retinal degeneration cleared up under use of this remedy. 

Mercurms dulcis is said to be especially useful in intersti- 



TREATMENT OF CHRONIC INTERSTITIAL NEPHRITIS. 241 

tial nephritis. In trie writer's experience it should not be 
given too low when there is a tendency to uraemic stomatitis 
which it greatly aggravates. 

Nitric acid. — Great weakness and prostration, especially in 
the morning with pressing pains in the lumbar region, nausea, 
excessive slimy secretions from mouth and throat, yellow 
coating all over the tongue with bitter or acid taste, bilious 
diarrhoea or constipation, haemorrhoids, anorexia, haematuria 
with urging after and shuddering along the spine during 
urination, skin dry, dark, dirty. Copious, pale urine of low 
specific gravity, and general symptoms of atonic gout. Use 
third decimal except as below when diuretic action is desired. 

Nitric acid is sometimes useful in alternation with Glonoin 
for its stimulating action on the kidneys when arterial tension 
is at the same time relieved by Glonoin. A. L,. Blesh recom- 
mends that it be given as follows : 

ffc. Nitric acid, c. p. , ^iv. 

Aqua dist., . q. s. ad. ,^ij. 

SiG. — Thirty minims in a full glass of water taken slowly after each 
meal. 

Nux vomica. — Gastric disturbances in interstitial nephritis. 
Nausea, vomiting, polyuria in irritable, morose patients. 

Plumbum metallicum. — Colicky pains proceeding from the 
spine, with obstinate constipation and retracted abdomen, 
marked tendency to uraemic convulsions, amaurosis from 
atrophy of the nerve, paralysis, slight dropsy, cutaneous anaes- 
thesia, exceedingly pale skin, chlorosis, rapid emaciation, 
progressive debility, mental depression. 

Glycerophosphates. — In one or two cases the writer has used 
the Phospho-gly cerate of Lime (Chapoteaut) in cases in which 
there was a ratio of urea to phosphoric acid above 13 to 1. 
In one case in which retinitis was a feature, apparent benefit 
was derived from use of the remedy. The patient, who had 
been unable to attend to his business on account of his eye 
trouble, recovered vision in a few weeks and went back to his 
16 



242 CHRONIC DIFFUSE NEPHRITIS WITH INDURATION. 

office. In another case of the same character, now under 
treatment, slight improvement only has taken place. 

Potassium citrate. — This remedy is fairly reliable, so far as 
its action goes, in cases where the urine is scanty and. the 
patient drowsy and in danger of uraemia. The writer has 
unquestionably relieved several patients who were sinking 
into coma by administration of Potassium Citrate in doses of 
from 15 to 30 grains in water, four times daily. Free action 
of the kidneys is obtained and the patient rouses from his 
stupor. 

SPECIAL THERAPEUTIC MEASURES. 

Headache is often obstinate, and may become a serious feat- 
ure, lasting for years. For the acute, blinding cephalalgia 
Glonoin is sometimes efficacious, but has failed even in enor- 
mous doses. For the chronic headache, Caffeine in one case 
gave most relief, but was not curative. Caffeine in the form 
of the uncombined, chemically pure alkaloid is now used in 
doses of 5 to 10 grains ; maximum dose, 10 grains at one time, 
30 grains in a day. Caffeine combined with small doses of 
Strychnine is sometimes more efficacious than Caffeine alone. 
Searle mentions a case which Baptisia tincture relieved most. 

Drop doses of the one per cent, solution of Nitroglycerin, 
every one to three hours, are quite commonly used when the 
headache or other symptoms of high arterial tension is severe. 

Dyspepsia is often ameliorated by warm baths. Cold baths 
should not be used, as they increase blood-pressure. 

For the dysentery rectal injections of solutions of Boracic 
Acid may be used. 

Nose-bleed. — This is sometimes a serious feature. If the 
patient can have medical attendance supra-renal extract is of 
service. Some of the powder is to be mixed with a little 
water and applied in a swab by use of the nasal speculum and 
mirror to the point of haemorrhage. Solution of Adrenalin 
may be used instead of the extract. In case these substances 
are not at hand try the following : 



SPECIAL THERAPEUTIC MEASURES. 243 

Hydrastis internally in ten-drop doses of the tincture every 
two or three hours, and a spray of a 5 per cent, solution of the 
fluid extract in water. External compression upon the bleed- 
ing nostril, either by the fingers, iced cloths, ice-bags or ice ; 
the hot nasal douche, water having a temperature of 90 F., 
injected until it emerges from the non-bleeding nostril un- 
mixed with blood ; ice in the mouth ; cold cloths, ice or cold 
metals applied to the spine ; immersing the scrotum in iced 
water ; Chapman's bags, containing water at a temperature of 
105 F., to the spine. 

Internal compression : by means of absorbent cotton 
pledgets which may be saturated with astringents in solu- 
tion ; by means of long, narrow strips of iodoform gauze, 
gently introduced until the nostril is entirely occluded ; by 
means of small rubber bags, on the principles of Barnes' 
dilators. Finally, plugging the posterior nares with Bel- 
locq's canula, which should be the dernier ressort, as it is 
not devoid of danger. 

A twenty per cent, solution of Antipyrine, applied on cot- 
ton pledgets, which are allowed to remain in situ, has been 
recommended as a reliable remedy. 

Uraemia. — The treatment has already been discussed. 
Sudden cases, as when convulsions occur, with little or no 
warning, may require Pilocarpine hypodermically. When 
uraemia threatens, Belladonna, Glonoin, and especially Can- 
nabis Indica in the lower potencies may be tried. 

Alarming symptoms may be relieved by free catharsis. 
Mercurius dulcis in one-grain doses of the first decimal, five 
or six times, at night, followed by a saline in the morning, is 
advantageous for this purpose. 

In cases where the patient is restless or wandering in his 
mind, has a heavy, foul breath and a coated tongue, salts 
should be given in the morning, and hot baths taken. Nitro- 
glycerine should be given the patient. 

If he is comatose, active purgation and sweating by use o£ 



244 CHRONIC DIFFUSE NEPHRITIS WITH INDURATION. 

Pilocarpine or hot baths should be brought about. In case 
of convulsions Chloroform may be used, and twelve to twenty 
ounces of blood removed by venesection (Osier). To the 
above may be added also the use of normal salt solution before 
described. In cases where restlessness and delirium are 
marked Osier has seen no ill effects from the use of Morphine. 
The writer can endorse this with the proviso that repeated 
hypodermics on the same day be avoided. 

High Arterial Tension. — When this is accompanied by 
symptoms of uraemia, the treatment is venesection, saline in- 
fusion and administration of nitrites. The combined treat- 
ment is especially valuable in averting threatening cerebral 
hsemorrhage. Five to eight ounces of blood are to be with- 
drawn, followed by the infusion of about fifty fluidounces of 
hot normal saline solution, together with full doses of Sodium 
Nitrite, three grains every four or five hours, as suggested by 
Carter. 

For milder cases Osier's suggestion is useful, namely, a 
light diet, occasional salines, sweating by means of hot air or 
other hot baths, and the cautious internal administration of 
Nitroglycerine, beginning with one drop of the one per cent, 
solution and gradually increasing to ten, three times daily, 
avoiding a dose which produces excessive flushing or head- 
ache, discontinuing after six or seven weeks' treatment, and 
then beginning again. 

This treatment is usually sufficient for cases in which head- 
ache, dyspnoea and dizziness are a feature. The writer fre- 
quently alternates Aconite in ten-drop doses of the second 
decimal with small doses (-g-g-0-tli grain) of Glonoin for a con- 
siderable period of time, weeks or months if necessary, until 
the dizzy spells cease for the time being. 

Chloral hydrate is often efficacious in relieving the dilated 
arteries. 

Cardiac Hypertrophy. — During this stage of the disease 
the smaller arteries are weak and liable to rupture, so that 



SPECIAL THERAPEUTIC MEASURES. 245 

there is danger from haemorrhages; hence keep patient as 
quiet as possible, restrict diet, and caution about running for 
trains, etc. Bowels to be carefully attended to in this stage ; 
a hard, full pulse, fulness in the head and vertigo call for 
free, watery stools. Give Glonoin in dose as above, or the 
Nitrites of sodium or potassium in 3- to 5-grain doses every 
four or five hours, or Potassio-cobaltic nitrite in 4- to 7-grain 
doses. The nitrites are less likely to cause headache than 
the glonoin. If acute uraemia is impending, do not give 
glonoin or nitrites. 

For acute intercurrent attacks at this time (shown by dimi- 
nution in quantity of urine, increase in albumin and casts) 
do not give Digitalis in large doses nor use hot-air bath, as 
they increase tension, but keep patient quiet, on low diet, 
and promote free action of bowels, using Citrate of Potassium 
as a diuretic. If necessary, give Elaterium for the bowels. 

It is not advisable to give glonoin or the nitrites in large 
doses continuously but only in emergencies. 

In the Stage of Cardiac Dilatation. — Digitalis, Caffeine, 
Strychnine, and Iron are the remedies for prolonging life. 
Give 5-drop doses of fat-free tincture of Digitalis, ^th grain 
doses of Strychnine sulphate or phosphate, or the Proto- 
chloride of Iron, according to the indications. Allow meat 
once a day. 

If the urine decreases in quantity, give Apocynum. Hot- 
air baths may be tried when the patient is not too weak. 

If dropsy increases, give Digitalis tincture in larger doses, 
say, 10 or 15 drops, with 5 or 10 drops of the fluid extract of 
Adonis, and that of Convallaria in 10- or 1 5-drop doses of the 
tincture, discontinuing for a few days if pulse becomes slow 
to a marked degree. 

Inhalations of Amyl nitrite or administration of the nitrites 
are serviceable for the over-action of Digitalis and similar 
drugs. Salines may also be necessary, even when diarrhoea is 
present, in order to reduce the dropsy. 



246 CHRONIC DIFFUSE NEPHRITIS WITH INDURATION. 

For inflammations of the lungs Digitalis and 20- to 30- 
minim doses of fluid extract of Ergot. 

Degenerative retinal lesions demand Iron and Strychnine ; 
hemorrhagic ones leeching of the temples aud 3 to 10 grains 
of Ammonium chloride in aqueous solution. 

For the acute uraemia of this stage (coma) give Jaborandi 
and Digitalis as before. 

Obstinate diarrhoea may be modified by Veratrum album, 
Arsenite of copper, or Gallic acid. 

The heroic treatment as described above will sometimes 
prolong life, but the outcome is always the same. 

In one case in this stage hydragogin failed utterly to pro- 
duce marked diuresis, although it increased the quantity of 
urine to a slight degree. In the writer's experience practically 
nothing has been of service. Aspiration of the chest for 
hydro thorax may produce temporary relief and saline trans- 
fusion may rally the patient when he is apparently moribund, 
but these measures merely delay the final outcome. The pa- 
tient's heart and lungs are in such a condition that capsular 
nephrotomy cannot be performed on account of danger from 
the use of the anaesthetic. 

Strophanthus must be used with caution in cases where there 
is advanced degeneration of the myocardium. 

In this stage the patient suffers from restlessness and 
insomnia. In advanced and hopeless cases a single hypo- 
dermic of morphine at night is often a necessity. In other 
cases chloretone, paraldehyde, trional, sulphonal, or chloral- 
amide may be adequate to produce sufficient sleep. When Mor- 
phine is given, one-eighth of a grain plus one two-hundredth of 
Atropine is the proper hypodermic dose. Digitalis should not 
be administered continuously. It is best to reserve it for emer- 
gencies, or to give it in alternation with Glonoin or the Nitrites. 
Caffeine may prove serviceable. Strychnine can usually, 
however, be given with safety in large and repeated doses in 
any stage of the disease. 



ARTERIOSCLEROTIC NEPHRITIS. 247 

For the dyspnoea supra-renal extract in doses of three to 
five grains every six hours may be tried. 

The patient will often be relieved from severe dyspnoea by 
the production of watery stools, for which purpose Epsom 
salt is serviceable. 

Surgical Treatment. — If the operation of capsular nephrot- 
omy is of value it should be tried in this disorder before the 
patient is in such a condition as not to be able to take an 
anaesthetic. The chances are, however, that he will be un- 
willing to be operated on in the earlier stages. Remissions 
of symptoms occur lasting for years sometimes ; during these 
remissions the patient seldom visits his physician, and would 
hardly be likely to realize the necessity for an operation. 

ARTERIO-SCLEROTIC NEPHRITIS. 

Definition. — A form of chronic diffuse nephritis with indura- 
tion in which, as a rule, there is inflammation of the inter- 
stitial tissue, together with sclerosis of the blood-vessels of the 
kidney. In rare cases there is primary arterio-sclerosis with- 
out any noteworthy changes in the stroma. 

The disease is, therefore, of vascular origin. 

Pathologic Anatomy. — The Kidneys.— -Normal in size or 
smaller, seldom larger ; hard and irregularly granular ; the 
color is cyanotic or reddish (beefy) in color. 

The Capsule. — Strips easily, but is adherent in places. 

Section. — Shows cortex reduced in size and of a dark-red 
color ; pyramids dark and congested, arteries like small, stiff 
tubes. 

The surface of the kidney may show cystic cavities, and in 
some cases may be gray rather than 'red. The consistence of 
the kidney is not so tough as in primary chronic interstitial 
nephritis. The connective tissue hyperplasia is focal rather 
than general, and calcification is seen in the partly destroyed 
glomeruli. 

Pathologic Histology. — The feature is an extreme thicken- 



248 CHRONIC DIFFUSE NEPHRITIS WITH INDURATION. 

ing of the blood-vessels, especially of the interna, not uni- 
formly in all parts of the kidney, but generally focal in dis- 
tribution. The pure form shows very little increase of the 
general fibrous tissue, but in the form combined with chronic 
interstitial nephritis it is not uncommon to find round-cell infil- 
tration and connective-tissue proliferation in the inter-tubular 
stroma. 

Diagnosis. — Osier says: "In persons over forty, with very 
high arterial tension, great thickening of the superficial ves- 
sels and marked cardiac changes, the renal condition is likely 
to be that of arterio-sclerosis, but for clinical purposes it is not 
necessary to differentiate from chronic interstitial nephritis.'' 

Treatment. — This should consider arterio-sclerosis in gen- 
eral. Diet and exercise are of prime importance. Articles 
rich in lime salts should be avoided, the quantity of food con- 
sumed not excessive nor the food fattening or indigestible. 
Milk, eggs, rice and spinach should be avoided as rich in lime 
salts. Patients between thirty-five and forty-five years of age 
must be especially careful not to take violent physical exer- 
cise. 

Boch {Zeitschrift f. Diaetet. und Physikal. Therapie, 1898, 
II., No. 1 ; Med. Rev. of Rev?) declares that arterio-sclerosis is 
a true disease. It begins during the forties, and may even 
appear in the thirties. It is both more common and more 
dangerous than valvular disease, a fact not sufficiently appre- 
ciated. It is not amenable to remedies ; while energetic pur- 
gation and venesection may temporarily relieve, diet alone 
holds out a prospect of cure. Diagnosis is not difficult ; it is 
sufficient to find permanent increase of blood pressure with 
permanent augmentation of the heart's action. 

Very different classes of people are predisposed to this dis- 
ease. First may be named good livers who suffer from pleth- 
ora. The very opposite class of half-fed and emaciated poor 
folk are also prone to become arterio-sclerotics ; here the 
causes are purely psychical — worry, etc. Men who speculate, 



ARTERIOSCLEROTIC NEPHRITIS. 249 

brokers, bankers and those of similar occupations, are also 
predisposed, while a fourth class comprises men who do hard 
manual labor and at the same time use alcohol to excess- 
Scoliokyphosis constitutes a special predisposition, due to the 
narrowing of the thorax, and consequent elevation of the 
blood pressure of the pulmonary circulation. Finally, arterio- 
sclerosis is often inherited. 

In general the diet should aim to cut down ptomaine- and 
leucomaine-producers on account of their deleterious action 
upon the vessels, and nucleo-albumins should be eliminated 
as far as possible. The following meats are permitted as be- 
ing poor in nucleo-albumins : So-called white meats, including 
veal, chicken, lean pork and lamb. Beef may be allowed only 
when thoroughly cooked. These white meats may be replaced 
by liver, kidneys, etc.; the latter are poor in albuminoids, and 
tend to prevent the organ-albumin from decomposition. Of 
vegetables, only those are permitted which do not form much 
gas. 

An arterio-sclerotic should never eat to repletion, because a 
distended stomach is a mechanical irritant to the heart ; for 
the same reason all gas-producing food is to be excluded. 

Alcohol, being a heart stimulant and vascular poison, should 
be avoided, with the exception of a little red wine or well-fer- 
mented beer, and even these are contra-indicated in advanced 
stages of the disease. Strong tea and coffee are forbidden. 

Remedies. — These are chiefly palliative. The most im- 
portant remedy is Iodine. Four grains of Iodide of Potassium 
in milk should be given twice a day until tolerance is estab- 
lished, when the dose is gradually increased to fifteen, three 
times daily. For a week out of each month it is omitted al- 
together, and after a number of months it is discontinued for 
a longer period than eight days. In this way it is given for 
at least a year and a half, or longer. 

The lactates are useful also, especially where there is angina 
pectoris. 



250 CHRONIC DIFFUSE NEPHRITIS WITH INDURATION. 

Rumpf uses the following : Sodium carbonate, 10 grams; 
I^actic acid q. s., to saturate; to this add L,actic acid, 10 
grams ; simple syrup, 10 grams, and distilled water, 200 
grams. Take the mixture once daily. 

In the stage where resistance in the vessels has begun to 
overpower the heart, rest, with inhalation of oxygen and skill- 
ful massage, resistance gymnastics and Nauheim baths are 
useful measures, together with non-nitrogenous diet and rem- 
edies to lessen blood pressure. 

Resistance gymnastics may be tried as follows : 

The patient executes certain simple movements of flexion, 
extension and rotation of the extremities and trunk, and these 
movements are carefully resisted by the physician or trained 
attendant. The resistance offered must never be great enough 
to embarrass the patient's breathing or circulation. If these 
and other directions are properly followed, the effect on the 
heart is striking and beneficial. The pulse becomes slower, 
stronger and fuller, the heart's sounds grow louder and the 
area of cardiac dullness diminishes, as shown by the position 
of the apex beat and by percussion. 

The remedies in this stage are chiefly Strophanthus, 
Strychnine, and Mercurius dulcis when needed. 

In the last stage, that of cardiac dilatation, Babcock advises 
the following : 

The sufferer should have rest and careful massage, with in- 
halations of oxygen. The diet must be light and simple, 
largely of milk, and all means must be considered that will 
allay or prevent flatulent distention of the abdominal viscera. 
Bowel movements should be kept free, so that the patient 
may not have to strain at stool. 

Strophanthus or Digitalin is required, and whatever cardiac- 
tonic is selected, it should be in conjunction with vaso-dilators, 
as the Iodides, Opium and the Nitrites. I consider Opium 
objectionable for several reasons, and generally prescribe one 
of the others. Nitroglycerine is the most frequently admin- 



ARTERIOSCLEROTIC NEPHRITIS. 251 

istered of all the nitrites. Brythrol tetrani trite is a new com- 
pound that is highly praised, because its effects are more last- 
ing, about six hours, and it does not so often affect the head 
unpleasantly. Nitroglycerine is very efficient, but evanescent, 
and, therefore, it should be taken every two or three hours. 
One-hundredth of a grain will dilate the arterioles powerfully 
without depressing the heart, and, therefore, this dose is suffi- 
cient as a rule. If cardiac asthma, nocturnal restlessness or 
insomnia occasion bad nights, a hypodermic of an eighth of 
Morphine with a two -hundredth of Atropine is excellent treat- 
ment. If cardiac dilatation and stasis become extreme, relief 
may be afforded by venesection, but is usually only temporary. 
When dropsy is extreme and does not yield to the usual diur- 
etics, astonishing results are sometimes obtained by Diuretin; 
incision or puncture of the ankles may also be done. In this 
stage Babcock regards the Schott treatment as of but doubtful 
utility and often of actual harm. 

Vigorous treatment may, and often does, bring some im- 
provement for a time. It is generally transient, and upon 
each recurrence of the symptoms subsequent amelioration is 
more difficult. At length there comes a time when all treat- 
ment is unavailing, and it becomes the physician's plain duty 
to mitigate suffering and promote euthanasia. This should 
not be considered necessary, however, until after all means 
have been tried and proved useless. 

Death usually comes through exhaustion, pulmonary oede- 
ma, or sudden arrest of the heart in diastole. Mild delirium 
may precede the end, or the senses be retained to the last. 



CHAPTER X. 



AMYLOID KIDNEY. 



Synonyms. — Hyaline, waxy, lardaceous, or albuminoid 
degeneration, or infiltration of the kidney. Depurative infil- 
tration of the kidney. 

Definition. — All affections of the kidneys are included 
under this head, in which the walls of the blood-vessels, espe- 
cially those of the glomeruli, are the seat of a degeneration 
with exudation which gives a chemical reaction resembling 
that of starch with certain reagents, as solution of iodo-potas- 
sium iodide plus dilute sulphuric acid ; the dirty violet color- 
ation given by starch with these reagents being noticed. It 
is called waxy, for the reason that the cut surface has this 
appearance. 

Forms. — Three varieties of amyloid kidney are distin- 
guished — pure amyloid degeneration, the amyloid large white 
kidney, and the amyloid contracted kidney. 

The most frequent form is the second, and produces a 
marked enlargement of the kidney. 

Pathologic Anatomy. — In typical cases we find the follow- 
ing : 

The Kidneys. — Greatly enlarged, has a hard, tough, elastic 
feel ; its color is pale, grayish-yellow, somewhat translucent 
like bacon. 

Capsule. — Easily removed. 

Sitrface. — Smooth, pale yellow, anaemic. 

Cut Surface. — Waxy appearance, rather dry, but little 
blood. 

Cortex. — Thickened, half the thickness of medulla, instead 
of the normal one-third or one-fourth. May be marked by 
reddish lines. 



AMYLOID KIDNEY. 253 

Glomeruli. — Quite dark and prominent ; size of millet 
seeds, dull, semi-translucent. 

Medulla. — Rays distinct, pyramids distinct and abnormally 
pale, less affected than the cortex. 

Note. — If an aqueous solution of iodine (iodine in iodide 
of potassium) be added to the cut surface, the amyloid patches 
of the latter instantly turn a dark mahogany color ; iodine 
and sulphuric acid give a violet appearance ; methyl-violet, 
or gentian, a red, while normal tissues are stained pale blue. 

The macroscopic features are pallor of the kidney and trans- 
lucency of the glomeruli. 

The vessels of the liver, spleen and intestines will often 
show similar degenerative changes. 

Microscopically we find : 

Glomeruli. — Rather enlarged ; glassy in part only at first, 
later wholly. 

Bowmarts Capsule. — Lining at first unaffected ; later, de- 
generated. 

Glomerular Capillaries. — Walls affected by homogeneous, 
translucent thickening. At first, minute paraffine-like masses 
occur in them. 

Afferent Arteries. — Walls affected by homogeneous trans- 
lucent thickening. 

Interlobular Arteries. — Walls affected by homogeneous 
translucent thickening. 

Basement Membrane of Convoluted Tubes. — Affected later. 

Epithelium. — Later becomes fatty, rarely amyloid. 

The features are first a homogeneous translucent thickening 
of the walls of the glomerular capillaries and afferent arteries 
occurring irregularly in patches, some of which are limited ; 
later involving the whole tuft of vessels in some places, the 
lining of Bowman's capsule, and even the basement mem- 
brane of the convoluted tubes with fatty degeneration of their 
epithelium. 

If the tissues of the kidney are stained with methyl-violet, 



254 



AMYLOID KIDNEY. 



or gentian-violet, trie amyloid portion takes on a clearly de- 
fined and characteristic red color, and it is shown that the 
amyloid degeneration begins in the walls of the small vessels, 
that the stroma may be affected later while the renal epithe- 
lium itself remains free from it, although atrophic and fatty 
changes occur. 




Fig. 16. — Waxy Degeneration of the Kidney in Chronic Croupous (non-indurative) 
Nephritis ; Formation of a Waxy Cast. IV, shining waxy lumps in the calibre of the 
tubule ; L, epithelia and endothelia of the tubule, partly in waxy change ; E. unchanged 
tubular epithelia; I, interstitial connective tissue. Magnified 600 diameters.— (From 
Heitzmann.) 



Etiology. — The disease is now said to be due to the long- 
continued action of the toxins of staphylococcus pyogenes 
aureus, the golden staphylococcus. Hence it is a disease 
secondary to chronic suppurative processes, such as occur espe- 
cially in tuberculosis, syphilis, osteomyelitis, cancer, and most 
commonly that of pulmonary and intestinal tuberculosis asso- 
ciated with ulceration and cavity formation ; necrosis of bone, 



AMYLOID KIDNEY. 255 

vertebral caries, old sinuses, long-discharging empyemas, 
chronic ulcerations of the skin or bowels, fistulas, psoas and 
lumbar abscesses, ulcerating cancer, especially uterine; pyo- 
nephrosis, purulent pyelo-cystitis, vesico-vaginal fistula and 
any obscure cachexia. 

It may result from pulmonary tuberculosis not accompanied 
by suppurating cavities. 

Bronchiectasis, localized suppurative peritonitis and actino- 
mycosis may lead to the formation of amyloid material in the 
kidneys. The writer has seen two cases of sarcoma, one of 
the orbit, the other intestinal, in which the disease occurred 
in the last few months of life ; also one case of general septi- 
caemia with localized manifestations in the kidneys and pleura 
in which waxy casts, known to be absent from the urine pre- 
viously, occurred in abundance during the last five days of 
life ; these, however, might have been also referable to a sup- 
purative peritonitis which was also present. 

Syphilis, even before ulcerative or suppurative changes, is 
said to be a cause of it It occurs sometimes late in the 
course of syphilis. Lead and mercury poisoning, gout, and 
malaria are given as causes. 

Suppurative nephritis in one kidney is often seen in cases 
where both kidneys were involved in chronic diffuse nephritis 
with amyloid degeneration. 

It is held by some writers that a syphilitic taint in con- 
nection with a suppurative process is absolutely essential for 
the production of the lesion. 

The disease is usually associated with amyloid diseases of 
the spleen, liver, and intestine, but it may be limited to the 
kidneys. 

L/itten found tuberculosis of the lungs in 70 per cent, of 
cases of amyloid kidney ; in 31 per cent, of these there were 
also tuberculous ulcers of the intestine. Rosenstein found 
out of 43 cases of amyloid kidney, 17 associated with ulcera- 
tive phthisis, and more than half of the latter were compli- 
cated with intestinal tuberculosis. 



256 AMYLOID KIDNEY. 

It is possible that the disease may arise without discover- 
able cause : primary toxaemia with resultant amyloid disease. 

Occurrence. — The disease is most common between the age 
of 20 to 50, but it may occur at any age when dependent on 
surgical diseases. 

Development. — It may take place even after a few months 
of a suppurative process. 

Diagnosis. — There is no infallible symptom. Cases in 
which there is an enlarged liver and spleen, together with 
the voiding of clear urine, abundantly albuminous and con- 
taining a few large hyaline or waxy casts, are likely to be 
amyloid kidney. 

Clinical Features. — In cases where the disease is not a 
complication of other renal lesions the cardinal features are 
polyuria, albuminuria, and amyloid disease in other organs. 
In addition we may find history of chronic suppuration or 
syphilis. The patient is anaemic, and in addition to pallor 
has muddy complexion, with brown rings about the eyes. 
Gastro-intestinal symptoms are common, especially vomiting 
and diarrhoea, together with dropsy and enlargement of the 
liver and spleen. 

Uraemia, dyspnoea, retinitis, and cardiac hypertrophy are 
rare. Vomiting is sometimes noticed as above. 

In some cases dropsy is absent altogether; in others is 
either moderate or severe. It is usually confined to the abdo- 
men and lower extremities. 

Secondary inflammations, as pneumonia, and also haemor- 
rhages are rare. 

In some few cases due to syphilis, bronchiectasis, and 
unilateral pulmonary contraction the general nutrition re- 
mains tolerably good for a considerable time and the patient 
lacks the pallid anaemic color to the skin. 

The most prominent features are, first, the enlarged abnor- 
mally firm liver with hard sharp lower edge, the enlarged 
hard spleen, and the obstinate diarrhoea. 



AMYLOID KIDNEY. 257 

The Urine is more or less increased in quantity in the ma- 
jority of cases, but sometimes is below normal, constantly 
contains much albumin, is clear, acid, of pale-yellow color 
and of specific gravity i.oio to 1.015. The sediment is scanty 
and contains but few casts, which are mostly large, hyaline 
and waxy. Pus- and blood-corpuscles are not abundant. 

The urine is often remarkably clear and may show no 
sediment to the naked eye. In addition to the large amount 
of albumin, 0.4 to 0.8 per cent, by weight, globulin may be 
present in relative abundance. In rare cases albumin is said 
to be absent. 

A rapid and frequent variation in the amount of urine and 
percentage of albumin is said to be characteristic of this 
disease. 

In well pronounced cases there may be as much as 3000 
c. c. (100 fl. oz.) of urine in the twenty-four hours, with a 
specific gravity of from 1.063 to I -o l 2. 

In cases where the large white kidney is also amyloid we 
find diminished urine of high specific gravity containing an 
enormous amount of albumin, up to three per cent, by weight, 
and in the sediment blood and pus corpuscles, fatty epithelia, 
and all sorts of casts including hyaline, granular, fatty and 
waxy. 

In cases where granular kidney (primary chronic interstitial 
nephritis) is also amyloid we find a large amount of albumin 
in urine of low specific gravity. A few hyaline casts occur 
in the sediment. Cases in which secondary chronic intersti- 
tial nephritis is complicated by amyloid degeneration we find 
the same as above, except that the quantity of the urine is 
not likely to be increased. 

Duration. — The disease may last anywhere from a few 
weeks or months to a year before death takes place. 

Differential Diagnosis. — The disorder is to be differentiated 
principally from chronic diffuse nephritis without induration. 
History of a chronic suppurative process, associated amyloid 
17 



258 AMYLOID KIDNEY. 

changes in the liver and spleen, and the clear urine with large 
amount of albumin, but very scanty sediment, serve to differ- 
entiate pure amyloid kidney from chronic diffuse nephritis 
without induration. 

Prognosis. — The majority of the cases terminate fatally. 
It is said that some recover completely, but these are prob- 
ably isolated cases. Fiirbringer has never seen one recover. 

In children where the disease is dependent on surgical 
affections the prognosis is more favorable ; also in syphilis. 

Exceptionally in such cases recovery may take place. 
Death takes place from progressive exhaustion or excessive 
oedema. 

Treatment. — Prophylactic treatment is of especial import- 
ance, and depends upon skillful management or removal of 
the exciting cause. It should be the effort of the physician 
or surgeon to put an end to any suppurative process as soon 
as possible. It is said that cases are rarer now than in former 
times, owing to the improvement in the surgical treatment of 
the various etiological conditions. 

Diet. — Purdy insists on a liberal and sustaining diet, the 
most nutritious compatible with the digestion, together with 
as much fresh air or moderate exercise as possible. Milk 
diet is not allowed, owing to the weakened condition of the 
patient. A good wine, as Burgundy, is highly beneficial at 
meals ; wine of pepsin may be used with benefit. 

Symptomatic Treatment. — The remedies commonly indi- 
cated are the Iodides (Arsenic, Potassium), Aurum muriaticum, 
Mercurius solubilis, Mercurius biniodatus, Hepar sulphur, Hy- 
drastis, Nitric acid, Lycopodium, Phosphoric acid. 

Potassium iodide should be given in syphilitic cases ; indi- 
cations already given under chronic interstitial nephritis ; use 
first decimal. 

Arsenic iodide given empirically by the writer in the sec- 
ond decimal when symptoms for Arsenicum occur in amyloid 
cases. 



AMYLOID KIDNEY. 259 

Aurum mur. — Indications given under chronic interstitial 
nephritis ; use third decimal or lower. 

Mercurins solubilis. — For syphilitic cases use third decimal. 
Mercurius biniodatus in the same potency in cases where there 
are old buboes discharging for years, together with amyloid 
kidney. 

Hepar sulphur. — In cases where abscesses are a feature use 
the third decimal. 

Hydrastis. — Febrile disturbances, with gastric and hepatic 
disorders, in cachectic patients. Chills morning or evening, 
heat in flushes all over the body, followed by great debility. 
Use second decimal. 

Lycopodium. — Carleton finds this remedy frequently indi- 
cated, inasmuch as the characteristic digestive symptoms are 
prominent, due to amyloid involvement of the mucous mem- 
brane of the stomach and intestines. There are sour eructa- 
tions, frequent belching without relief, heart-burn, waterbrash 
nausea after cold, but not after warm, drinks ; fullness and 
flatulency in the stomach and bowels ; gnawing, griping in 
the gastric region ; all symptoms are worse from 4 to 8 p. m. 

Phosphoric acid. — Useful in cases of tuberculosis and other 
suppurative processes ; there is mental indifference, pain in 
the back, disturbances of nutrition ; use the first decimal. 

Palliative Treatment. — In cases where the exciting cause 
can not be removed by surgical treatment, the following may 
be tried : In tuberculous cases, Creasote, Guaiacol, and the 
like ; in syphilitic cases, Mercurial inunctions and Iodide of 
Potassium ; in malarial cases, Arsenic, Iron, Quinine. 

If there are lymphatic enlargements, Calcium chloride in 
five-grain doses, in milk, may be given. 

If there is extreme weakness, dilute Phosphoric acid. 

For digestive troubles, Nux vomica, Bismuth, Peptenzyme, 
Diastase, Pepsin, Caroid ; the wine of pepsin is said to be par- 
ticularly good for these cases. 

For excessive albuminuria Gallic acid in two-grain doses or 
more. 



260 AMYLOID KIDNEY. 

For the obstinate diarrhoea try Acetate of Lead in small 
doses of the crude drug, if nephritis be absent (shown by 
scantiness of sediment, few casts); rectal administration of 
deodorized tincture of Opium is sometimes successful. When 
intestinal ulceration exists, the diarrhoea is best controlled by 
Copper sulphate, one-tenth of a grain, and Belladonna tinct- 
ure, with rectal administration of Opium. When dropsy and 
scanty urine are a feature, hot air-baths and diuretics will be 
needed. 

Cathartics may cause obstinate diarrhoea in amyloid kidney, 
and in tuberculous cases Iron should not be given internally. 

Kichhorst gives the Iodide of Iron in amyloid disease as 
follows : Equal parts of syrup of the Iodide of Iron and simple 
syrup. Dose, a dessertspoonful three times daily. 

INFILTRATIONS OF THE KIDNEY — DEGENERATIONS OF THE 

KIDNEY. 

Calcareous Infiltration. — This may occur in chronic in- 
terstitial nephritis in cases where there is atrophy of bone 
with absorption, as in old persons, in poisoning by certain 
substances as Corrosive sublimate, Phosphorus, Bismuth, 
Aloin, etc., and in cases of pyelitis where the urine is decom- 
posed in the pelvis ; Calcium oxalate may be deposited in the 
kidneys in conditions favoring its formation, either of diet or 
metabolism. 

The deposits are whitish or grayish -white, and may be 
found in the pyramids or on the surface. 

Uratic Infiltration. — Deposits of urates occur in gout and 
in the uric acid diathesis. They may appear as yellowish- 
white lines in the pyramids, but chiefly occur in the cortex. 

Uric acid infarcts are an almost constant feature in the 
urine of the new-born. As a rule they disappear promptly, 
otherwise they lead to irritation, and by blocking the tubules 
may cause uraemic phenomena. 

Argyrosis or deposits of silver may occur following the 



INFILTRATIONS OF THE KIDNEY. 261 

ingestion of large quantities of silver salts, especially the 
nitrate. The deposit is found chiefly in the cortex, and in 
rare cases has been known to be due to local applications of a 
salt of silver to the mucous membrane. 

Glycogenic Infiltration occurs in diabetes mellitus, and 
involves especially the epithelium of the loop of Heale. 

Necrosis of the convoluted tubules is often present in asso- 
ciation, especially in cases dying suddenly of diabetic coma. 

Dropsical Infiltration (hydropic change or oedema) is com- 
mon in acute inflammation ; it affects both epithelium and 
stroma. 

Leukemic Infiltration is often found in leukemia of the 
kidney affecting the stroma, with an enormous accumulation 
of leucocytes. The kidney is much enlarged and mottled, 
with grayish-yellow areas ; uric acid infarcts may occur at the 
same time. 

Bilious Pigmentation occurs in jaundice. In the icterus of 
the new-born the so-called bilirubin infarct occurs. 

Hemoglobin Pigmentation is found in cases of poisoning by 
agents such as Hydrogen Arsenide, Carbolic Acid, Potassium 
Chlorate, etc.; also in infectious diseases, especially malaria, 
extensive burns, exposure to cold (paroxysmal hemoglob- 
inuria), etc. 

The kidneys are enlarged and of a brownish-red color. 

Amyloid Degeneration is the result of suppurative diseases. 
(See Amyloid Kidney.) 

Hyaline Degeneration is probably closely allied to the 
above and may precede it ; both are often associated in the 
same kidney. It is frequently found in chronic interstitial 
nephritis and affects the glomeruli chiefly. Calcareous infil- 
tration may occur in the hyaline areas. 

Cloudy Swelling occurs in the course of infectious diseases 
and in poisoning by Arsenic, Corrosive Sublimate, Phosphorus 
and the mineral acids ; mercurial treatment for syphilis may 
cause it. It is one of the most frequent processes in the kidney 



262 DEGENERATIONS OF THE KIDNEY. 

and affects the epithelial cells, particularly those of the con- 
voluted tubules. It results in enlargement of the kidney. 
The surface has a peculiar opaque appearance, so that the 
organ looks as if it had been cooked. The process has a 
marked tendency to pass into fatty change, but may undergo 
retrogression, in which case the kidney assumes a more or less 
normal appearance. The clinical features are increased fre- 
quency of urination and diminished urine containing albumin, 
blood and casts. There is no oedema and no arterial tension. 
The treatment in cases of poisoning is to eliminate the poison 
and to administer the proper antidote. In the course of infec- 
tious diseases the usual remedies for the primary disease should 
be administered, or other remedies called for by urinary symp- 
toms, among which Apis, Belladonna, Terebinth are most fre- 
quently indicated. 

Fatty Change. — This accompanies severe inflammation and 
is especially common in the large white kidney. It may also 
be due to ansemia, to the toxins of infectious diseases, acute 
yellow atrophy of the liver, and certain poisons as Arsenic, 
Chloroform, Phosphorus, etc. The convoluted tubules are 
most affected. The treatment is that of the cause. 

CHRONIC DEGENERATION. 

Etiology. — Due to cachexia as of tuberculosis or cancer ; 
most commonly to circulatory obstruction from cardiac or 
pulmonary diseases ; may arise without known cause. The 
disease may follow passive hypersemia. 

Morbid Pathology. — The kidneys may be normal in size or 
enlarged and heavier than normal. The surface is smooth 
and the markings distinct. Congestion of the pyramids is a 
marked feature. There is a swollen, granular condition of 
the epithelia lining the uriniferous tubules, and the condition 
is one of chronic degeneration of these cells. 

Clinical Features. — The history is usually one of passive 
hyperaemia, and the symptoms progressive weakness and 



SYPHILIS OF THE KIDNEY. 263 

emaciation with death from asthenia. The nrine may be 
normal or contain a small amount of albumin and a few 
casts. The treatment consists in nutritious diet, attention to 
the general health and administration of remedies symptomat- 
ically, as Arsenicum, China, Phosphorus, Phosphoric acid, 
Rhus tox. 

SYPHILIS OF THE KIDNEY. 

Syphilis of the kidney occurs in the form of gumma but 
rarely. When found, gummas are in the cortex or in the 
pyramids, rarely in both at the same time. They vary in 
size from that of a pinhead to a hazelnut. As many as 
twenty to sixty may be found. There may be suppuration or 
a diffuse gummatous infiltration in which the kidney becomes 
enlarged even to such an extent as to weigh seventeen ounces 
even as early as two months after infection. Symptoms sug- 
gesting acute or subacute nephritis may occur due to syphilis. 

In acute cases the disease may appear in two to three 
months after the chancre is seen. The kidney resembles that 
of acute post-scarlatinal nephritis. The clinical features are 
diminished urine, frequent micturition and the abnormal con- 
stituents of scarlatinal nephritis. CEdema, headache and 
digestive disturbances occur. The prognosis is favorable. 
The dietetic and hygienic treatment is the same as in acute 
nephritis. The principal remedy is Mercurius cor. or sol. in 
the third decimal. 

Chronic cases are found in later stages of syphilis. The 
kidney may be either contracted, amyloid, or gummatous. The 
symptoms are those of chronic nephritis in general. When 
the gummata break down, the urine contains a large amount 
of debris, is of dirty-brown color, and contains albumin, blood 
and epithelial casts. The treatment is anti-syphilitic, with 
milk or mixed diet, regular hours and hygiene (Carleton). 

Leprosy. — Leprous lesions are rare, but various non-specific 
inflammations of the kidney are not rare in leprosy. 



264 TRAUMA AND FISTULA. 

Glanders. — In human glanders the kidney is seldom af- 
fected. 

Actinomycosis. — In this disease the kidney may be second- 
arily involved. In one instance a case of what appeared to 
be primary renal actinomycosis was observed. 

Leukemia. — Lymphomatous nodules are found in the kid- 
neys in typhoid fever and sometimes in other infectious dis- 
eases. 

TRAUMA. 

Synonym. — Injury to the kidney. 

Etiology. — Commonly due to puncture, gun-shot wounds, 
or external violence. 

Clinical Features. — As a rule but one kidney is injured. 
The symptoms are immediate shock and collapse, pain in the 
region of the kidney, local haemorrhage and haematuria. 
Rupture of the kidney manifests itself by a swelling and rise 
in temperature, not usually above 105 F. Anaemia may 
occur. 

Treatment. — This consists in rest, hot applications and 
stupes. Internally the remedies are Aconite, Arnica, Bella- 
donna, Chamomilla and Veratrum viride. 

Nephrectomy may be necessary in cases of peritoneal in- 
volvement, otherwise drainage and packing of the wound 
with iodoform gauze. In rupture of the pelvis the edges 
should be sutured when possible, and in cases of dislocation 
of the kidney suture to the abdominal wall is advised by Car- 
leton. 

FISTUMS. 

These are seldom of surgical origin, but more commonly 
due to traumatism or rupture of abscess, presence of foreign 
body, excessive, long-continuing suppuration, incomplete 
drainage, etc. 



FISTULA. 265 

Fistulse are either renal-intestinal, opening into the colon 
and attended by vomiting and purging of pus and urine ; 
renal-gastrie, which are very rare, but may occur in cases of 
calculus ; renal-bronchial and external renal fistula. The last 
named are usually quite direct and open in the lumbar or 
inguinal region. 

An erythematous patch of integument surrounds > the ulcer- 
ated opening, from which pus and urine escape. The treat- 
ment is free direct drainage, whenever possible. The ureter 
should be either rendered previous or, if this cannot be done, 
nephrectomy is indicated if the other kidney is normal (Carle- 
ton). 



CHAPTER XL 



SUPPURATIVE NEPHRITIS. 



Synonyms. — Acute interstitial nephritis with suppuration. 
Abscess of the kidney. Pyelo-nephritis. Surgical kidney. 
Purulent nephritis. 

Classification. — We distinguish two classes according as 
infection reaches the kidneys ; first, hsematogenic, embolic or 
metastatic suppurative nephritis, and, second, urogenic sup- 
purative nephritis. 

Etiology. — Bacteria are the direct exciting cause. They 
may reach the kidneys through the blood or lymphatics on 
the one hand, or by way of the urinary passages on the other. 
Hence we distinguish the two forms, hematogenic and uro- 
genic purulent nephritis. 

• 

HEMATOGENIC SUPPURATIVE NEPHRITIS. 

In this disease we find the infection due to conveyance of 
bacteria by the blood-stream, hence it is found in general py- 
emic conditions, in ulcerative endocarditis, in osteo-myelitis, 
diphtheria, scarlet fever, dysentery, small-pox, puerperal in- 
fection, bed-sores, pulmonary tuberculosis, and actinomycosis. 
The sequence may be, in some cases, first, the infectious pro- 
cess ; second, ulcerative endocarditis, local abscesses, or sup- 
purative thrombo-phlebitis, or arteritis, and, third, suppurative 
nephritis. 

Infectious or septic emboli containing bacteria, as from in- 
fectious endocarditis, infectious thrombus of the lungs, or 
some vein, being transferred to the kidneys, cause abscess 
there. Hence malignant endocarditis, resulting from a num- 
ber of diseases, may be the cause of it. 



UROGENIC SUPPURATIVE NEPHRITIS. 267 

In general it may be an accompaniment of infectious pro- 
cesses localized elsewhere in the body. The micro-organisms 
capable of producing it are primarily the common pyogenic 
cocci, then the pneumococcus, and, in rare instances, the ty- 
phoid bacillus and the actinomyces. 

Pathologic Anatomy. — We find yellowish-white nodules, 
variable in size and number, in the kidneys, which are visible 
through the capsule and represent small abscesses. There 
may be only a few or the whole kidney may be riddled with 
them. 

The size of the abscess varies from that of a pin-head to a 
hazel-nut, or, in rare instances, even larger. They are sur- 
rounded by a red areola, sometimes by distinct haemorrhages. 
The kidneys are, as a rule, both affected, are enlarged and 
sometimes quite soft. The cortex is usually wider than nor- 
mal and both it and the medulla show yellowish areas of sup- 
puration. Microscopically the abscesses show themselves as 
dense collections of polymorphonuclear leucocytes, which in- 
vade the interstitial tissue and fill the lumen of the tubules 
and the capsular space of the glomeruli. It is often possible 
to find bacterial emboli as the cause of the abscesses. Degen- 
eration of the renal tissue within the confines of the suppura- 
tive process always occurs. 

As pyaemic abscesses seldom communicate with the urinif- 
erous tubules, there may be no great amount of pus found in 
the urine. 

UROGENIC SUPPURATIVE NEPHRITIS. 

This is the disorder commonly known as surgical kidney, 
an ascending infection of the kidney produced by suppurative 
processes anywhere in the urinary tract. 

Etiology. — Cystitis, especially that due to vesical calculus, 
is the most common cause, producing pyelitis by infection, 
which in turn produces suppurative nephritis. Less com- 
monly pyelitis, due to stone or tumor, is a cause. Ureteritis 



268 SUPPURATIVE NEPHRITIS. 

from compression by tumors may also be a cause ; the ureters 
are seldom much altered by infection ascending from the 
bladder. Gonorrhoea and stricture are also causes. 

Pathologic Anatomy. — The kidney may show either one 
abscess or a great number ; in the latter case they may be 
either discrete or confluent. The size varies from that of a 
pin-head to one large enough to fill the whole space between 
renal capsule and renal pelvis. 

When the abscess results from extension of the inflamma- 
tion from below, we find opaque, grayish, bead-like streaks 
along the pyramids from apices to renal cortex, having an in- 
jected border, and tending, as they enlarge, to become conflu- 
ent \ soft in the center, and to form an abscess. 

Usually one kidney only is affected, especially when pri- 
mary pyelitis is a cause, but even when due to cystitis both 
kidneys are not necessarily affected. The kidney is enlarged, 
hyperaemic and soft; in advanced cases the papillae melt away, 
and in extreme examples the organ is converted into a large 
pus sac, to which condition the term pyonephrosis is applied. 

The principle organism responsible for the infection is the 
Bacillus coli communis (acid urine), next the Proteus vulgaris 
(ammoniacal urine). 

Microscopically we find that the collecting tubules may con- 
tain in earlier stages colonies of bacteria, often of the Bacillus 
coli ; the epithelium is necrotic ; the adjacent interstitial tis- 
sue infiltrated with leucocytes. The epithelium of the convo- 
luted tubules undergoes granular degeneration. In long- 
standing cases the abscesses may be surrounded by a more or 
less well-defined connective tissue wall. 

Results of the Abscess. — Previous presence of renal ab- 
scess is shown by a scar, which is depressed, or by a calcified 
nodule. If the suppuration extend to the paranephric fat 
tissue, we have paranephric abscess. This, or the renal ab- 
scess, may communicate with the pelvis of the kidney, or 
with the gastro-intestinal tract. 



^ 



UROGENIC SUPPURATIVE NEPHRITIS. 269 

The abscess may rupture into the liver, pleura, bronchi, the 
peritoneum, or even externally, forming a renal fistula. In 
some cases the pus becomes encapsulated or absorbed, the 
acute process terminating in a chronic fibroid change in the 
kidney. Amyloid disease may result. 

Diagnosis. — This may be difficult, especially in the hsema- 
togenous form. In the cases of pyelo-nephritis the history of 
previous urinary disease, the onset of septic symptoms, and 
the presence in the urine of micrococcus casts, together with 
pus, albumin, and possibly blood, are the most characteristic 
features. 

It is difficult to draw a sharp line in ascending cases be- 
tween pyelitis and pyelo-nephritis, since the one usually 
merges into the other. 

Clinical Features. — In cases due to endocarditis the symp- 
toms may not be perceived. In cases due to trauma or sur- 
gical interference there is a violent and repeated chill, fever, 
sweat, vomiting and other digestive disturbances, together 
with pain and swelling in the region of the kidneys. In as- 
cending cases the features may be divided into three groups, 
as follows : 

i. Those of general sepsis. 

2. The local alterations in the kidney. 

3. The changes in the urine. 

The symptoms of general sepsis are as follows : 

1. Irregular chills, with corresponding elevations of temper- 
ature. 

2. Continued intervening fever, with not so high temper- 
atures as during the chills ; sometimes remittent fever. 

3. Various nervous, digestive, circulatory and respiratory 
symptoms, as in fevers ; the symptoms may simulate uraemia. 

4. The patient has generally an anxious expression ; face 
at first flushed, later sallow or jaundiced ; mouth dry ; tongue 
coated (often brown), fissured, crusted ; pulse rapid, feeble ; 
there may be pallor, thirst, loss of appetite, headache, vomit- 



270 SUPPURATIVE NEPHRITIS. 

itig, hiccough, diarrhoea, profuse sweats, drowsiness, sopor, 
and low delirium. 

The local symptoms in the kidney are as follows : 

Pain which is either spontaneous or provoked by pressure ; 
the pain is seldom severe unless there has been an injury to. 
the kidney or an involvement of the peritoneum. 

The kidney is usually palpable, and at times there is fluctu- 
ation ; in some cases the distention of the kidney by pus is 
such that a tender tumor may be readily perceived in the 
loin. 

The Urine. — In metastatic abscess we may be unable to find 
marked evidences of the disease in the urine. 

In pyelo-nephritis we find alkaline, offensive urine, with 
more albumin than the pus accounts for, and swarms of 
micro-organisms. 

Even though the urine is alkaline, tube-casts composed of 
pus, but more commonly of micrococci, may be found in 
small numbers with a little care. In the writer's experience 
they are of the utmost value in confirming the diagnosis. 
Occasionally, in severe cases, a day or two before death they 
may be numerous and easily found. 

In some cases we do not find more albumin than the pus 
accounts for. 

There is not uncommonly blood in the urine due to perfor- 
ation of the blood-vessels by the destruction of tissue. 

Rarely there are found fragments of desquamated renal 
tissue — renal sequestra — which may be as large as a pigeon's 
egg^ and which microscopically show the features of renal 
tissue. 

In some cases there is polyuria and urine of low specific 
gravity. Not rarely we observe vesical tenesmus and pain on 
urinating. 

In children pyelo-nephritis manifests the following feat- 
ures : 

i. The presence of severe gastro-dyspeptic symptoms, such 



OTOGENIC SUPPURATIVE NEPHRITIS. 271 

as anorexia and vomiting, with pain in the region of the kid- 
neys, and the long continuance of these symptoms. 

2. Constipation. There may be shedding of large pieces 
of membrane, mingled with hardened faecal masses. 

3. The variability of the urine, changing from a perfectly 
healthy specimen to one containing large quantities of albu- 
min, pus, morphotic elements and mucus. 

4. The peculiar type of fever, intermittent in character 
with chills and general malaise, which may be accompanied 
by a gradual but constant emaciation. 

5. The urine in cases of pyelo-nephritis shows, according 
to Baginsky, the presence of the bacterium coli in pure cul- 
ture. 

Course. — The course of the disease may be either acute, sub- 
acute, or chronic. In old cases of urinary disease, purulent 
nephritis sometimes runs a rapid course ; the writer has seen 
several patients who lived but a week or two after the first 
severe chill. In other cases the patient may survive several 
months or longer. 

Complications. — Pulmonary oedema, erysipelas, dropsy, 
paranephric abscess. 

There may be renal colic from passage of pus through the 
ureters, and acute hydronephrosis from obstruction of the 
latter. If the obstruction is not relieved, ursemia and urinary 
septicaemia may ensue ; in some cases paralysis of the lower 
extremities — urinary paraplegia — may be observed. 

Rupture into the abdominal cavity is speedily followed by 
a rapidly fatal peritonitis. 

Differential Diagnosis. — Injury, or signs of a malignant en- 
docarditis, together with the clinical features and urine as 
above, distinguish the abscess sometimes called metastatic. 
History of disease of the lower urinary tract or surgical opera- 
tion on the same point to the surgical kidney. 

Suppurative nephritis is distinguished from pyelitis by the 
graver constitutional symptoms, viz.: Irregular high temper- 
ature, delirium and chills, with a tender tumor in the loin. 



272 SUPPURATIVE NEPHRITIS. 

The intermittent presence of pus in the urine is more likely 
to be due to suppurative nephritis, while a continuous but re- 
mittent flow of pus in an acid urine suggests tuberculous, cal- 
culous, or obstructive pyelitis. 

Prognosis. — Depends on whether the pus is absorbed or 
discharged into the urinary or gastro-intestinal tract ; in the 
latter case, prognosis is serious. When one kidney only is in- 
volved, patient may live some little time.. When both kid- 
neys are affected, prognosis is serious. Prognosis is also 
usually serious in patients who have had prolonged obstruc- 
tion to escape of urine from a stricture or enlarged prostate. 
Recovery is, however, possible in these cases, but permanent 
renal atrophy results. In pregnancy the prognosis is favor- 
able, the case being a removable pressure. 

In a few cases spontaneous cure is effected by the inspissa- 
tion of the pus forming masses resembling putty, in which a 
deposit of lime salts may take place. 

In cases due to trauma or surgical interference, recovery 
may take place or the patient pass into a typhoid condition 
and die. 

In cases due to enlarged prostate death is the rule, as is the 
case usually when the disease is of bacterial origin. 

Cause of Death. — Death is usually preceded by profound 
coma. Convulsions are rare. In cases where there is rupture 
into the abdomen, peritonitis is the cause of death. Death 
usually takes place, however, from progressive exhaustion or 
urinary sepsis. 

Prophylaxis. — If the patient has a chronic disease of the 
lower urinary tract, all instruments used must be thoroughly 
sterilized. Enforced retention not allowed ; patient to be 
supplied with rubber urinals. Avoidance of cold and damp 
to be enjoined, sitting on cold or wet objects to be prohibited. 

The urine may be efficiently sterilized in many cases by use 
of Uro tropin in doses of seven and one-half grains (0.5 gm.), 
two to four times daily in plenty of water. 



UROGENIC SUPPURATIVE NEPHRITIS. 273 

Diet in Reral Abscess. — The patient being put to bed the 
following diet is advised : Soups, milk, yolks of eggs free 
from white and beaten up with brandy ; arrowroot flavored 
with Madeira, broth from veal stock thickened with cream 
and arrowroot, boiled sago or tapioca with a little milk. 
Stimulants to be given freely if there is much asthenia. If 
urine scanty, give large quantities of diluents, barley water, 
linseed tea, warm water, but no saline diuretics. 

Liquid peptonoids, Somatose, beef peptonoids, malted milk, 
clam broth, matzoon, and fresh buttermilk may be given. 

Treatment. — Apply antiphlogistine to the region of the 
kidneys, and give one tablet of protonuclein every two or 
three hours. Dry cupping may be tried for relief of conges- 
tion and to favor diuresis. Dampen the bottom of an ordi- 
nary tumbler, drop in a piece of loose, dry cotton, moisten the 
skin with warm water, light the cotton, invert the glass in- 
stantly, and, if the cotton sticks to the bottom of it, apply to 
the region of the kidneys. 

If a cupping-glass with rubber bulb be at hand, the above 
process may be dispensed with. 

Open the bowels once daily with warm enemata or mild 
purgatives. 

Hot fomentations and hot baths, if possible, are of service. 

Remedies. — As palliatives the remedies are the urinary dis- 
infectants, as Salol, Urotropin, Boric acid, Eucalyptus and the 
Benzoates. 

In one case, apparently due to pyelitis, a mixture of corn- 
silk, broom-tops and lithia, known as lithiated sorghum com- 
pound, in teaspoonful doses, apparently hastened recovery. 

Elaterium may be needed if there is obstinate constipation 
with scanty urine, or Ergot, if with polyuria. 

If foul urine accumulates in the bladder, there is probably 
less risk in drawing it off than in letting it stay ; after cathe- 
terization an antiseptic solution may be introduced. 

The writer has had considerable experience with the solu- 
18 



274 SUPPURATIVE NEPHRITIS. 

tion of Boracic acid suggested by Ralfe, namely, pure Boracic 
acid, 1 20 grains; Glycerin, one fluidounce ; hot water, eight 
fluidounces. A few teaspoonfuls daily will usually suffice to 
keep the urine acid and prevent decomposition. In some 
cases, however, even this agent fails. 

It should be tried, however, in cases in which Urotropin 
fails, as it sometimes does, to render the urine clear and acid 
in nature. 

Symptomatic Treatment. — The usual remedies are Aconite, 
Arnica, Belladonna, in the beginning ; Hepar sulphur, Silicea, 
and Veratrum viride later. These remedies should not be for- 
gotten when, for any reason, surgical treatment is impossible. 
Hekla lava and Sodium sulphocarbolate aie also suggested by 
Carle ton. 

Surgical Treatment. — In unilateral cases nephrotomy is the 
treatment when the diseased organ still contains considerable 
healthy tissue, otherwise nephrectomy is necessary. The cap- 
sules of one or both kidneys may be incised in order to relieve 
tension. 

PARANEPHRIC ABSCESS. 

Synonyms. — Suppurative paranephritis, perinephric ab- 
scess. 

Definition. — Purulent inflammation of the fat capsule of 
the kidney. The terms perinephric abscess and perinephritis 
are used synonymously with paranephritis, but should be con- 
fined, strictly speaking, to inflammation of the fibrous capsule, 
and not to that of the fibro-fatty tissue in which the kidney is 
embedded. 

Etiology. — Due to extension of inflammatory process from 
elsewhere, or from a wound, surgical operation, or various sup- 
purative lesions. Occurs in the sequence of infectious dis- 
eases, especially typhus, typhoid, and small-pox. 

Most commonly found in suppurative nephritis, chronic 
renal tuberculosis, or by extension from appendicitis, spinal 



PARANEPHRIC ABSCESS. 275 

caries and empyema. It is found in association with lumbar 
and psoas abscesses, suppuration of the retro- peritoneal 
glands, traumatic infections, perforation of the intestine and 
pyaemia. Perinephritis may, in addition, be produced by op- 
erations on the kidney. 

Paranephric abscess may result from purulent absorption in 
cases of inflammation of the connective, tissue about the 
uterus, vagina, or rectum after childbirth, and is not an un- 
common complication of pelvic cellulitis. 

It may follow surgical operations on the testicle or sper- 
matic cord after inflammation of connective tissue about the 
bladder ; or operations on the rectum, perinaeum, or uterus. 

Suppurations in the gall-bladder, liver and spleen may be 
followed by it. 

In a few cases it seems to result from invasion by the Bacil- 
lus coli communis without traumatism, especially in middle- 
aged men apparently in perfect health. It may be due to can- 
cer or echinococcus of the kidney, to carcinoma and tubercu- 
losis of the vertebrae, to duodenitis, psoitis and purulent 
pleuritis. Paratyphlitis and ulcers in the colon may be a 
cause. In some cases renal embolism has been known to 
cause it. 

Occurrence. — Twice as often in men as in women. More 
frequent in adults than in young people. 

Diagnosis. — A painful swelling in the loin with fever sug- 
gests paranephric abscess. (See also Differential Diagnosis.) 

Onset. — In some cases the disease may have an insidious 
onset and merely complicate other diseases, with a prolonged 
course and very moderate constitutional symptoms. If ap- 
pendicitis is the cause, the onset is sudden and the progress 
rapid. 

Clinical Features. — Following some one of the etiological 
conditions above mentioned is noticed a chill, fresh rise of 
temperature, sweating and deep-seated lumbar pains radiating 
into the thigh and testicle, with later a painful swelling in 
the loin. 



276 SUPPURATIVE NEPHRITIS. 

The fever is a common feature ; it is often intermittent and 
associated with chills and thirst ; the temperature is persist- 
ently elevated, however, in many cases. There are disturb- 
ances of digestion, constipation, debility and emaciation. 
The respirations may be quickened, the swelling may extend 
upward and crowd the diaphragm, causing dyspnoea. 

There may be severe shooting pains in the leg, numbness 
and paresis. 

As a result of the fever and pain the patient may become 
thin and feeble to an extreme degree. 

The patient has a constrained attitude and bends forward 
toward the diseased side. When in bed he lies on the dis- 
eased side, holding the vertebral column convex toward the 
healthy side, with the lower extremity of the diseased side 
flexed at the hip and knee-joint (Eichhorst). 

The feature above described, namely, bending of the trunk 
toward the affected side, is said to be a valuable diagnostic 
sign. 

If the collection of pus lies anteriorly, the patient is more 
likely to lie with the thigh flexed and to complain of pain 
radiating into and about the hip-joint and the testicle. 

Localized Symptoms. — i. Swelling occupying lumbar 
region ; space between lower ribs and crest of ilium some- 
times bulges. If not, the swelling may be perceived by 
bimanual examination, with patient in dorsal position. 

2. Pain in region of the kidneys, worse on pressure ; some- 
times extends into the legs, worse on movement. 

3. Skin in region of the kidneys congested and oedematous. 

4. Marked mobility of the kidney. 

In general a painful tumor in the region of the kidneys, to- 
gether with fever, points to paranephric abscess. 

The Urine. — 1. Features of renal congestion ; trace of al- 
bumin ; a few blood corpuscles. 

2. If pus is present with pelvic epithelia, pyelitis co-exists. 

3. Sudden large quantity of pus shows rupture of abscess 
into the urinary tract. Fat in abundance may be present. 



PARANEPHRIC ABSCESS. 



277 



4. Unless the abscess results from trauma or pre-existing 
urinary disease, urine may be normal, except when abscess is 
so large as to cause renal congestion. 

5. Aspiration may reveal presence of pus, when urinary ex- 
amination is negative. 




Fig. 17. — Perinephritis. — (Morris.) 

Differential Diagnosis. — It is to be distinguished chiefly 
from suppurative nephritis. In paranephric abscess we find 
a large tumor, so that the space between the lower ribs and 
crest of the ilium sometimes bulges. In suppurative nephritis 
there may be merely a well-defined lumbar swelling extend- 
ing downward. The urine, in cases not due to trauma or pre- 
vious urinary disease, is normal, that of suppurative nephritis 
never normal. For other features in the differential diagnosis 
see table of diagnosis of tumors. 



278 SUPPURATIVE NEPHRITIS. 

Abscess in connection with spinal caries may suggest para- 
nephric abscess, and may even open into the pelvis of the 
kidney. Molecular fragments of carious bones may be found 
in the pus and assist the diagnosis. 

Moreover in spinal and hip-joint disease we find the charac- 
teristic deformities and limitation of motion. 

From renal calculus it is distinguished by the presence of 
constitutional disturbance and by physical examination ; from 
appendicitis by the history and the location of the pain and 
swelling ; from abscess of the gall-bladder in a similar way ; 
from psoas abscess by the fact that in psoas abscess the pus 
tends to point in the groin, and the swelling and pain are an- 
terior to the anterior axillary line ; from lumbago by the 
fever, tenderness, swelling and lateral inclination. 

Course. — The course may be either acute (four to six 
weeks), subacute (several months) or chronic (longer than 
four months). 

Effects. — May extend both upward and downward and per- 
forate the loin, perinseum or groin, the urinary tract, vagina, 
intestinal tract, or the peritoneum or pleura. 

Pleurisy is a common complication ; it is usually serious 
and on the same side. 

The duodenum is sometimes perforated by the abscess. 

Paranephric abscess is a large one, hence the liability of 
neighboring organs to be perforated by it. 

If the pus is absorbed or encapsulated, a chronic fibroid in- 
flammation usually takes place and involves the kidney-cap- 
sule and para-renal tissue. The kidney is then ensheathed in 
a thick mass of cartilaginous hardness, to which it is usually 
adherent. Total necrosis of the kidney may follow throm- 
bosis of the renal artery, due to contraction of the para-renal 
tissue. 

Prognosis. — Depends on that of the cause. 

Favorable if cause can be remedied, when disorder primary 
and recent, provided early surgical treatment is resorted to, 
with drainage. 



PARANEPHRIC ABSCESS. 279 

Unfavorable if pus is allowed to burrow, since abscess may 
rupture into peritonaeum, pleura or intestines. 

Unfavorable when secondary to grave renal lesions, or those 
of neighboring organs. 

Unfavorable when secondary to spinal disease. 

Most unfavorable when the disease follows the puerperal 
state in septic conditions, or violent infection in long-standing 
kidney troubles. 

Recovery possible in cases where patient has strong consti- 
tution, even after bursting into bowels. 

Recovery follows both absorption of pus and spontaneous 
evacuation, when cause of disease is remediable. 

Recovery from spontaneous evacuation presupposes free 
drainage and freedom from sepsis. 

Death may take place from septicaemia, embolic abscesses, 
progressive emaciation, exhaustion, or lardaceous degeneration 
of the kidneys (amyloid kidney); or the patient may sink into 
a typhoid condition. 

Treatment. — Absolute rest, milk diet, free movements of 
the bowels, cold applications (ice bags) when as yet no red- 
ness or fluctuation. Cupping and application of leeches may 
relieve the pain and congestion. Inunctions of Belladonna or 
application of a liniment of Chloral and Camphor, equal parts, 
for the pain ; Morphine by mouth or rectum may be necessary. 

As soon as pyrexia and rigors suggest suppuration, aspirate 
and apply large hot poultices. 

If fluctuation can be made out, and there is increase in the 
symptoms, an incision is advised with drainage. 



CHAPTER XII. 



CYSTS AND TUMORS. 



. We have to distinguish between simple cysts and cystic 
degeneration. In the writer's opinion this distinction is not 
usually made sufficiently clear in the books. Cysts may be 
found in kidneys otherwise healthy, in which case there may 
be only one cyst or several, and the usual size is not larger 
than an apricot, though cases occur in which they are of size 
sufficient to make an abdominal tumor. Cysts are found in 
diseased kidneys, in which case they are multiple and some- 
times innumerable, and in greater or less numbers are a con- 
stant accompaniment of chronic interstitial nephritis. There 
may be combined cystic disease involving the liver and spleen 
as well as the kidneys. 

When now the cysts occur in diseased kidneys in such 
numbers and of such size as to exceed all other changes in 
the kidney, and to produce extreme enlargement of the organ, 
forming an abdominal tumor, the term multilocular cystic kid- 
ney or polycystic kidney is used. 

MULTILOCULAR CYSTIC KIDNEY (POLYCYSTIC KIDNEY). 

Definition. — Enlargement of the kidney due to formation 
of innumerable cysts in one, or usually both, kidneys, produc- 
ing symptoms resembling those of renal atrophy. 

Etiology. — All cysts probably arise from dilatation of the 
tubules or of Bowman's capsule, caused by obstruction to es- 
cape of urine. Congenitally, absence of ureter or other mal- 
formation interfering with escape of urine may cause the dis- 
ease, and in adult life chronic interstitial nephritis, by distal 



MULTILOCULAR CYSTIC KIDNEY. 



281 



constriction of uriniferons tubes, may cause proximate dilata- 
tion of them by the urine, but in addition there is usually 
symmetrical enlargement of both kidneys in the cases occur- 
ring in adult life. 



P^C 



M 




Occurrence. — The large majority of cases in adults are con- 
genital, though possibly in some cases it may be an acquired 
disease. It may occur in several members of the same family ; 
the writer has seen it in a brother and sister. Most of the 
congenital cases die ante-partum or shortly after delivery, 
which accounts for the rarity of the condition among adults. 



282 CYSTS AND TUMORS. 

In many cases the condition is not discovered until post-mor- 
tem. The condition is often associated with other malforma- 
tion, as hare-lip, club-foot, absence of renal pelvis and ureters, 
or absence of the duct of Botal. 

Pathologic Anatomy. — The shape of the kidney is in the 
main retained, the size enlarged from that of a fist in congen- 
ital cases to that of an infant's head in adult cases, and the 
weight increased, reaching from 2 to 16 pounds. Both kid- 
neys, as a rule, are uniformly enlarged, spongy, and lobulated 
from presence of innumerable cysts of all sizes, the larger 
ones the size of plums and usually in the centre of the organ, 
separated from one another by an intervening grayish-white 
fibrous structure. The cysts occupy both medulla and cor- 
tex. Renal tubules and glomeruli are here and there recog- 
nizable in the fibrous structures. The cysts are essentially 
closed cavities. 

Contents of Cysts. — The cysts contain fluid varying in 
consistence and in color. A thin, watery fluid is common, 
but viscid, syrupy, caseous or almost solid contents may be 
found. Urinary salts and albumin are found in the thin 
liquid, as well as blood-pigment. The more solid contents 
consist of fat-granules, epithelium, cholesterin, uric acid and 
triple phosphate. It is said that urea is not found in the cyst 
fluid. 

Symptoms. — In the fcetus the abdomen may be so distended 
as to interfere with childbirth or preyent the descent of the 
diaphragm, causing death from asphyxia or paralysis of the 
heart. The longer the person lives the larger the diseased 
kidney, the number of cysts increasing with the growth of 
the person. In adults the symptoms are those of chronic in- 
terstitial nephritis (enlargement of left ventricle, increased 
tension, pallor, cachexia) plus haematuria, obstinate in char_ 
acter, and usually a bilateral, soft, non-fluctuant renal tumor, 
with sense of tension and pain in the loin. In later stages 
nausea, vomiting, headache and suppression of urine are ob- 



MULTILOCULAR CYSTIC KIDNEY. 283 

served. The patient dies of coma, or more frequently of con- 
vulsions ; less frequently of exhaustion following renal haem- 
orrhage, bronchitis, pneumonia, or pulmonary oedema, with 
severe dyspnoea. 

The disease may remain latent and be discovered only at 
autopsy, or it may remain latent for a long period and then 
suddenly lead to fatal uraemia. 

In a case which the writer saw, in a man about 40 years 
old, there had been for three years no symptoms other than 
the urine of chronic interstitial nephritis and the presence of 
an enormous tumor in each lumbar region, of the shape of the 
kidney, containing nodulations and protuberances easily made 
out. Six months before death slight hematuria appeared, the 
urine diminished in quantity while albumin, leukocytes and 
epithelial debris increased. He began to complain of abdom- 
inal distention and weight, and of headache, vertigo and visual 
disturbances. Haematuria and uraemic symptoms became 
more marked. 

A few days before death the urine contained so much albu- 
min that it became a solid mass in the Esbach tube on addi- 
tion to the urine of the picric acid solution. The patient 
died of coma, which lasted several hours. At the post-mor- 
tem, which the writer attended, the kidneys were found to be 
enormously enlarged. The right kidney weighed six pounds 
and the left five and one-half pounds, several hours after 
removal from the body. There was perfect, complete and ab- 
solute metamorphosis of the kidneys into a congeries of cysts. 

The complete analysis of the urine in this case was pub- 
lished by the writer in the Philadelphia Medical Journal. 
Aceto-soluble albumin was found in the urine. 

The clinical history and results of post-mortem examina- 
tion have been narrated by Dr. I. N. Danforth in American 
Medicine, July 5, 1902. 

Effects. — The tumor may cause displacement upward of 
the liver, spleen, diaphragm and lungs, and death may take 



284 CYSTS AND TUMORS. 

place from suffocation or paralysis of the heart. The tumor 
may rupture and cause perforating peritonitis. 
Differential Diagnosis. — 



CHRONIC INTERSTIT] 


AL 






NEPHRITIS. 




CANCER. 


CYSTIC DISEASE 


No tumor. 




Tumor. 


Tumor. 


Hematuria, not 


com- 


Hematuria. 


Hsematuria, 


mon or obstinate. 




obstinate. 


No pain. 




Pain. 


No pain. 


No cachexia. 




Cachexia. 


Cachexia. 


Patient over 40. 




Patient under 
5 or over 60. 


Patient 40 to 55 



The tumor in cancer is rapid in growth, nodular, and of un- 
equal resistance ; in cystic disease, bilateral, of slow growth, 
non-fluctuant and soft, preserving the shape of the kidney, 
while the aspirating needle withdraws fluid. 

Prognosis. — In the new-born child, if appreciable enlarge- 
ment is found, early death may be predicted. 

In the adult prognosis is unfavorable, but patient may live 
for years after discovery of tumor. 

Dangers. — Suppression of urine, coma, and especially con- 
vulsions ; exhaustion from obstinate hsematuria ; pulmonary 
lesions. 

Treatment. — The medical and hygienic treatment is that 
of chronic interstitial nephritis. Absolute rest and adminis- 
tration of styptics, when there is hematuria. The latter may 
resist all treatment. 

It is possible that in some cases puncture of the cysts or 
nephrectomy may be performed, if the other kidney is healthy. 
According to Osier death took place in a case in which one 
kidney was removed. 

HYDATID CYSTS. 

Formation. — Due to encapsulation and proliferation of the 
parasite taenia echinococcus. 

Etiology. — The disease may occur at any age, but most 



HYDATID CYSTS. 285 

commonly between twenty and fifty. It is slightly more 
common in men than in women. 

The use of uncooked meats and salads in places where dogs 
live in close association with their masters is sometimes a 
feature in the history. 

Position. — The cysts are usually unilateral, on the left side, 
and unilocular. 

Diagnosis. — A tumor in the loin, with vesicles, scolices or 
hooklets in the urine, points to echinococcus. 

Clinical Features. — The tumor is likely to be large, filling 
the whole side of the abdomen. It may show by quick, 
short, bimanual percussion-strokes, a peculiar whiz known as 
hydatid vibration. Passage of the daughter-cyst through the 
ureter may occasion renal colic. If the cyst rupture into the 
kidney, hooklets may be found in the urine. Aspiration 
should reveal the same (Fig. 19 {p.) ). 

After the passage of the vesicles through the ureter there is 
further trouble expelling them through the urethra. Reten- 
tion of urine takes place, with excessively frequent desire to 
pass water and severe pain extending to the head of the penis. 
Expulsion of the vesicle requires considerable force and may 
take place with a loud sound followed by passage of urine 
looking like soap-suds. 

Differential Diagnosis. — Hydatid cysts are to be distin- 
guished from cystic kidney, abscess of the kidney and hydro- 
nephrosis. If there are no scolices or hooklets in the urine, ex- 
ploratory puncture may reveal them. The tumor may sup- 
purate and resemble abscess of the kidney. The renal colic 
may be mistaken for that of calculus. 

Effects. — Pressure on other organs may produce asphyxia, 
palpitation and cardiac pain. 

Prognosis. — Uncertain, usually unfavorable. 

Treatment. — Surgical. Occasional cures are claimed. 

When the cyst has ruptured, and the vesicles are being 
freely discharged from the bladder, there remains little for us 



286 



CYSTS AND TUMORS. 



to do but to watch the progress of the case. The abdomen 
should be firmly bandaged, and gentle friction employed over 
the tumor to aid their escape. The patient should be warned 
against undue exertion or engaging himself in any occupation 
likely to cause strain during their discharge for fear suppura- 
tive action be excited, or even rupture of the discharging cyst 






Fig. 19 (a).— Taenia Echinococcus complete. X about 16.— (Porter. 




Fig. 19 (b). — (B.) The circle of hooklets seen upon its under surface; thirty-four in 
number, seventeen long and seventeen short. (C) b, c, Lateral views of the separate 
hooklets— £. the base; c, the central extremity or bifid process of the base; e, hooklets 
viewed upon the concave or inferior border; f y g, k, a diagram illustrating the movements 
and position of the hooklets.— (Ralfe.) 

caused. As diuretics have been found to assist the discharge 
of the vesicles, these remedies may be administered, and if 
there is much pain from colic during their passage, sedatives 
should be combined with them. 

In other cases nephrotomy or nephrectomy is to be per- 
formed. The possibility of cure from injection of Mercuric 



BENIGN TUMORS. 287 

chloride solution (1:1000) into the tumor has been considered. 
Dermoid Cysts. — These may occur in the kidney, but they 
are very rare. In cases where small reddish hairs are found 
in the urine the possibility of such a tumor occurring must be 
considered. 

TUMORS OF THE KIDNEY. 

We distinguish two varieties, benign and malignant. 

Benign tumors are fibroma, lipoma, myoma and adenoma. 
Some writers mention myxoma, angioma, lymphoma, chon- 
droma, osteoma, cavernous tumors and gummata. 

Malignant tumors are sarcoma and carcinoma. 

BENIGN TUMORS. 

Lipoma. — These are among the rarest of tumors. They are 
sharply circumscribed, somewhat wedge-shaped neo-forma- 
tions, situated, for the most part, in the cortex. They do not 
grow much above the size of a hazel-nut. (D. J. Hamilton.) 

Warthin observed a lipoma which weighed two pounds and 
microscopically presented the features of a fibrolipoma. 

Fibroma. — According to Hamilton, this is a round growth 
about the size of a mustard-seed or larger, gray in color, and 
much resembling a tubercle. It will often be found lying in 
the medulla. It is usually a single tumor, and is composed 
of fibrous tissue arranged more or less concentrically. 

They may be mistaken for tubercles, but are harder, more 
glistening and more circumscribed. 

In rare cases they attain a very large size ; Wilkes observed 
one that weighed over 37 pounds. The kidney sometimes 
consists of a conglomerate mass of fibromas of considerable 
size. Fibromas tend to become cystic. Cholesterin is often 
present in the cyst-fluid, and calcification of the solid portions 
of the tumor is not rare. 

Myoma. — The kidney is comparatively often, according to 



288 CYSTS AND TUMORS. 

Hamilton, the seat of a tumor usually described as striated 
myoma. It is always congenital, and, although small at the 
time of birth, gains bulk rapidly, so that at death it may dis- 
tend the abdomen and weigh several pounds. It is located at 
first around the kidney, and subsequently envelops and de- 
stroys it. Some cavities filled with thick, brown-colored 
liquid may alone indicate the former locality of the organ. 
It is firm in consistence at parts, soft at others, and sometimes 
throughout its substance little barley-seed-like masses of hy- 
aline cartilage may be detected. The whole aspect of the 
tumor is that of a sarcoma, but there are microscopical differ- 
ences, some of the cells showing a distinct cross striation. 

Rhabdomyoma usually grows in connection with the kid- 
ney, sometimes with the testis, and is always congenital. 

Liomyoma, composed of unstriped muscle-tissue, occurs 
with extreme rarity in the kidney in association with fibroma. 

Osteoma and Chondroma have been found in the kidney, 
but are extremely rare. 

Pure myxomas are very rare, but myxomatous degeneration 
of other connective tissue tumors is common and gives rise to 
the belief that the tumor is really a myxoma. (Riesman.) 

Cavernous angiomas, such as are found in the liver, are also 
met with in the kidney. They are bright-red masses, from 
the size of a cherry to that of a walnut, and are usually situ- 
ated beneath the capsule, sometimes in the pelvis, constitut- 
ing a cause of hsematuria. 

Adenoma. — Adenoma is sometimes a multiple growth ; the 
tumors reach the size of a pea or hazel-nut, or even larger. 
They project from the surface and are mostly sub-capsular. 
If large, they push the kidney aside and are sharply demar- 
cated from it. Sutton holds that the only tumor of the kid- 
ney to which the term renal adenoma is applicable is what is 
known as congenital cystic kidney. 

Shattock maintains that remnants from the meso-nephros 
(Wolffian body) and the meta-nephros (true kidney) often 
serve as matrices. 



MALIGNANT TUMORS. 289 

Lymphadenomas have often been found growing in the 
kidney. 

Adenomas are generally small, whitish and multiple, and 
occupy the cortex ; they may attain a large size and become 
cystic. By excessive proliferation and bursting of the base- 
ment membrane adenomas may be transformed into carcin- 
omas. 

Adenoma may proceed from displaced portions of the supra- 
renal capsule. 

Benign tumors are, as a rule, rarely of practical importance, 
owing to insufficient size and number. 

In some cases, the kidney being absorbed from disease, its 
place is taken by true adipose tissue. In a case operated on 
by Dr. Charles Adams, complete replacement by fat took 
place in connection with a large retroperitoneal tumor (lipo- 
myo-fibroma). 

Villous papillomas grow occasionally in the kidneys. 

Clinical Features. — In benign growths there may be no 
features recognizable, until the tumor has attained such a size 
as to cause discomfort by reason of its weight and the press- 
ure exerted on surrounding organs, and it is rarely that non- 
malignant growths attain so large a size. 

MALIGNANT TUMORS. 

These are sarcoma and carcinoma. They occur both as 
primary and secondary tumors, and are distinguishable from 
each other only by microscopical examination. 

Sarcoma. — This is the most common malignant renal 
tumor. Primary ones are occasionally seen in the adult kid- 
neys. They are usually of the round-cell type, and may grow 
to a great size. Sutton distinguishes three species, as follows : 

i. Spindle-celled sarcoma and its variety, myosarcoma. 

2. Round-celled sarcoma. 

3. Tumors composed of adenoid tissue. 

19 



290 CYSTS AND TUMORS. 

In a very large proportion of cases they are congenital or 
are noticed within a few months of birth. 

The growth of sarcoma is rapid, and the tumor usually 
reaches an enormous size before it destroys life. The mass is 
smooth, and pseudo-fluctuation is usually present. The tumor 
is composed usually of round cells. The malignancy of sar- 
coma of the kidney is very great, and recurrence after extirpa- 
tion of the kidney is the rule. (Senn.) 

The occurrence of sarcoma in the kidney is of great import- 
ance in the general theory of tumors, since it points definitely 
to development of new growth from scattered portions of em- 
bryonic tissue. The striped muscular fibres found in them 
cannot possibly come from the kidney. 

As to the etiology of sarcoma we find the following : 

It has a very striking tendency to occur in childhood rather 
than in adult life. It has been found in still-born infants. 
The female sex is more frequently affected than the male. 
The left kidney is more often affected than the right ; some- 
times it is bilateral. 

Trauma is important in the etiology ; it occasionally de- 
velops in floating kidney. 

Peculiar mixed tumors occur in the case of children, but 
are very rare, though not unknown, in adults. In addition to 
the ordinary sarcomatous elements, glandular tissue, non- 
striped and striped muscle-cells and sometimes cartilage are 
found. For a time they grow slowly and then, especially 
after trauma, they take on rapid growth, attaining in a few 
months the size of a child's head. Metastasis takes place late 
and even in absence of it cachexia develops. 

The left side is more likely to be affected, but the disease 
may be bilateral. The average weight is eight pounds, but 
as high as thirty-six pounds has been observed. Microscopi- 
cally, tubular structures are striking features of these tumors, 
resembling the collecting tubules of the kidney ; a stroma 
made up of round or spindle-cells also occurs. 



MALIGNANT TUMORS. 291 

The urine, as a rule, in these eases is free from albumin or 
blood, and operative removal is of doubtful value. 

A peculiar and anomalous tumor is met with in rare cases 
lying in or around the kidney substance, to which it is diffi- 
cult to assign a name. It grows to the bulk of a walnut or 
orange, is rounded, sharply cut off from the kidney-tissue, and 
provided with a capsule. A striking feature on section is the 
diversity of color of the exposed surface, suggesting a sarcoma 
in some parts, but in others there are cyst-like cavities filled 
with deep-brown-colored thick fluid, evidently the remains of 
an old haemorrhage. (Hamilton.) 

Carcinoma. — There is undoubtedly a primary cancer of the 
kidney which springs from the epithelium. The tumor may 
grow to such an extent as to occupy the whole of one side of 
the abdomen. It is extremely hard and tough, and nothing 
may remain of the affected kidney but a number of cysts filled 
with a thick brownish-red fluid. Most cases described as car- 
cinoma are really sarcoma. 

Carcinoma of the kidney is of the tubular variety, and the 
columnar epithelia are arranged in the form of tubules in a 
delicate, very vascular stroma. 

According to the degree of development of the stroma the 
tumor is either hard or soft, of slow or of rapid growth. In 
exceptional cases the tumor, instead of springing from a matrix 
of embryonic cells representing kidney-tissue, originates from 
a displaced matrix of epithelia derived from the supra-renal 
capsule. 

True carcinoma, developing from the adult epithelial cells 
of the kidney, is rare, but secondary cancer may occur in the 
kidney as in other organs ; chorio-epithelioma (deciduoma 
malignum) not rarely gives metastasis to the kidney. 

Primary carcinoma is usually unilateral and occurs as a 
diffuse infiltration. Secondary carcinoma is more likely to 
be bilateral and occurs as circumscribed nodules. 

The growth may be either dense and fibrous, soft and med- 



292 CYSTS AND TUMORS. 

ullary, or consist of cavities containing colloid material, 
hence the terms fibrous, medullary and colloid cancer. 

MALIGNANT DISEASE IN GENERAL. 

Etiology. — Primary malignant disease is more common in 
males than in females, and in early or late adult life. Occa- 
sionally it is found at birth. 

Secondary malignant disease takes its origin from malig- 
nant disease in the vicinity, and especially from primary 
malignant disease of the testicles. 

It is said that malignant renal disease is frequent in the case 
of girls in whom there is an abnormally early growth of hair 
on the pubes and in the axilla, and who exhibit peculiar pig- 
mentation of the skin. 

It is common in children under four years of age. 

It has been found several times combined with cancer of 
the testicle. 

Renal calculi seem to cause development of carcinoma. 

Pathologic Anatomy in Carcinoma. — The disease may af- 
fect one or both kidneys. In secondary malignant disease the 
right kidney is more often affected. The disease occurs as 
diffuse infiltration or as nodules, the latter being more fre- 
quent in secondary cancer. 

Character of the Tumor (Carcinoma). — The affected kidney 
is, as a rule, increased in size, but its shape is usually main- 
tained. The surface of the tumor is usually lobulated. The 
mass varies in consistency, throughout or in different portions, 
from scirrhous to soft medullary or encephaloid. The color 
varies according to conditions present, as fatty degeneration, 
necrosis, haemorrhage or pigment formation, hence may be 
gray, whitish-yellow, red or black. 

The tumor may in some cases be enormous in size, as large 
as a man's head, producing appreciable distention of the ab- 
domen and displacement of the abdominal viscera, and may 
weigh as much as twenty pounds. 



MALIGNANT DISEASE IN GENERAL. 



293 



Location. — The fibrous capsule of the kidney may overlie 
the tumor or may have been perforated by it, or the capsule 
may separate the tumor from the kidney. 

The neoplasm may grow into the renal vein, and from there 
into the inferior vena cava. It frequently projects into the 
renal pelvis, dilating and completely filling it. 




Fig. 20.— Cancer of the kidney.— (Rayer. 



Diagnosis. — The essential features in the diagnosis of ma- 
lignant growths of the kidneys are as follows : 

1. The position of the tumor. 

2. Its limited mobility. 



294 CYSTS AND TUMORS. 

3. The relations to the colon. 

4. The age of the patient (child or old person). 

5. The occurrence of an unaccountable haematuria in an 
old person. 

Clinical Features of Malignant Growths in General. — These 
are the following : 

1. Pain and pressure. 

2. Progressive emaciation and cachexia. 

3. Hsematuria. 

4. Swelling. 

The pains are either fixed or else shoot outward and down- 
ward from extension of the growth to the lower dorsal and 
lumbar nerves ; usually a dull ache or paroxysmal pain, and 
not affected by movement. When there is pressure on lum- 
bar nerves, there may be extreme pain in the chest, lumbar 
region, back, hip, testicles, thigh and leg. 

The patient may complain of a dull, aching, lumbar pain, 
sometimes radiating along the course and distribution of the 
genito-crural nerve. In some cases there is scarcely any pain 
for a long period of time. 

Pressure on the sciatic nerve may cause sciatica and paresis ; 
pressure on the diaphragm, lungs and heart may cause dysp- 
noea, palpitation and a sense of constriction about the chest. 

The pressure, if on abdominal veins, may cause oedema of 
lower extremities or ascites ; if on abdominal viscera, then 
vomiting, anorexia, icterus and irregular bowel movements. 

Cachexia is especially significant, when the patient has not 
lost much blood and still has fairly good appetite. Cachexia 
is sometimes but little noticeable in sarcoma. 

Hematuria may be an early symptom. It may be constant 
or intermittent, slight, or sufficiently severe to prove rapidly 
fatal. Renal colic may be noticed from passage of clots of 
blood (worm-like) which may be found in the urine. In 
elderly persons haematuria often precedes recognition of 
tumor. 



MALIGNANT DISEASE IN GENERAL. 295 

The blood is frequently voided as clots, which often show 
as moulds of the ureter or even of the pelvis of the kidney, or 
the blood may be entirely fluid. 

The bleeding may be frequent, rare, or entirely absent. 
There is renal colic only when large clots are passed. 

It is unusual to find small particles or shreds in the urine ; 
the writer thinks, however, that they might be found more 
often if precaution were taken to dissolve the blood in water 
by dilution with several times its volume. 

The Tumor. — When large enough to be palpable, is found 
to be a deep-seated mass in the lumbar region, which may be 
movable, lobulated, and across which inflation of the colon 
will show the latter to pass. The tumor does not move with 
respiration. In some cases fluctuation may be noticed. 

Persistent violent pain in the region of the kidney, which 
cannot otherwise be accounted for, with progressive cachexia, 
warrants the gravest suspicion of malignant disease, even 
though other features are absent. 

Persistent hematuria (whose renal origin may be suspected 
by the dark color, absence of clots, etc.), with cachexia, sug- 
gests renal cancer, even if pain is absent and no enlargement 
can be detected. 

Guillet declares that an important symptom of malignant 
disease is the presence of a suddenly-occurring and rapidly- 
growing varicocele. 

Considerable difficulty and pain on micturition are noted in 
early stages of malignant disease, even when the bladder is 
not affected. 

Various Symptoms. — A constant and marked increase in the 
pulse-beat has been noticed ; eventually there is marasmus, 
but general symptoms may be late in appearing. 

The patient walks with the body bent forward and is afraid 
to rotate or flex the vertebrae. 

The Urine in Cancer. — In addition to the blood, epithelia 
and fragments of the tumor may be found. Connective tis- 



296 CYSTS AND TUMORS. 

sue in large amounts may be a feature. (See writer's Urinary 
Analysis, 3d Ed., Chapter XLIX.) 

Glycogenic generation in the epithelia is of diagnostic im- 
portance, according to Quincke. 

The urine in sarcoma has been described in the writer's 
book on Urinary Analysis, page 322. Heitzmann demon- 
strated the sarcoma corpuscles, midway in size between the 
blood-corpuscle and the pus-corpuscle. (See also page 322 in 
Urinary Analysis, by the writer.) 

In carcinoma the occurrence in the urine of numerous epi- 
thelial cells, and especially cell groups with multiple nuclei, 
is a suspicious sign. 

Differential Diagnosis. — Bimanual palpation may show 
the following in cases of cancer of the kidney : 

1. Tumor in the lumbar region of the shape of the kidney. 

2. Location behind the colon (determined by inflating the 
latter). 

3. Tumor not movable. 

5. Tumor separated by the intestine from liver and spleen 
(shown by resonance on percussion, unless intestine is pushed 
aside). 

6. If the tumor is soft and lobulated, aspiration may remove 
a liquid containing urea and cancer fragments. 

The tumor must be differentiated from enlarged spleen, 
tumors of the liver, distended gall-bladder, pelvic tumors, as 
of the ovaries ; large psoas abscess, tumors of the retro-peri- 
toneal glands. 

Enlarged spleen may be felt as a moving body with char- 
acteristic edge ; it moves with respiration. 

Tumors of the liver and a distended gall-bladder are easily 
movable, and are not overlaid by the distended colon ; they 
are also more superficially placed and jaundice is a prominent 
symptom. 

Pelvic tumors proceed from below and are not covered by 
the intestine. Their movement is lateral and downward. 



MALIGNANT DISEASE IN GENERAL. 



297 



Fluid pushes forward. 
Aspirated fluid, neutral 
or feebly acid, never al- 
kaline. 

Intermittent discharge of 
pale, watery urine. 

But little constitutional 
disturbance. No dropsy, 
no cachexia. 


Hsematuria rare. 


Painless or feeling of 
weight and dragging. 


Varies in size from time 
to time. 


n 

w 

3^ 

P* 
►i 

3 s 

3 


2 

ET.3 

32- 

m 3 
en p 

*3. 

p ^ 

>-t p 

p. en 
P 
►1 

3^ 

n 

8 

3 


Tumor, unilateral or bi- 
lateral. 


Hydronephrosis. 


Urine not intermittent. 

Eventually well-marked 
cachexia. L,oss of flesh. 
Anaemia. Ascites and 
cedema lower extremities 
when pressure on abdom- 
inal veins. 


Fluid accumulations push 
forward. 


c £ 
Pf 

A 
n 



3 
-1 

§• 

Oq 

3* 

n 

3 


8." 

3 3 
p 

p. 

p 

3 


en 

8 

en 
P 

3 


No variation in size. 


3 
w 
c 

p" 
>-t 

5 1 

-t 

3 


Non-fluctuant. 


Unilateral. 


Cancer. 


Sallow complexion, hyper- 
trophy of heart, arterial 
tension as in interstitial 
nephritis. Sometimes 
dropsy. 


3' 

n 



5" 

m 
1 

3 

n> 
3 


Fluids push forward. In 
hydatid cysts, aspirated 
fluid never acid, some- 
times neutral, usually al- 
kaline. 


Hsematuria moderate until 
late. 


Usually painless until sup- 
puration. 


No variation; hydatid cysts: 
diminution in size of 
tumor after renal colic. 


3* 
P 
•d 

n 


tt 

Si 

3 

n 


3 

3 
33 

3 

2 

3 
p 
s 


G 
3 

p 

n 

I 


-1 

2". 


H 
O 



en 
M 

en 

H 


May be signs of ursemic 
poisoning, but usually ab- 
sence of marked fever. 


Intermittent discharge of 
muco-purulent urine. 


If due to renal calculus, 
hsematuria after exercise. 

Fluids push forward. Aspi- 
rated fluid contains pus. 


Considerable pain in lum- 
bar region, worse on pres- 
sure in front, relieved by 
pressure behind. 


Varies in size. 


►1 
ra 
OP 

3 

P* 
1 

S" 

1 


2 
3 

3 
P 

3 


a 

3 # 

p 
re 

2 


P 

2 
5 


Pyonephrosis. 


Great constitutional dis- 
turbances; continuous el- 
evation of temperature. 
Marked rigors and sweat. 


Urine not intermittent. 


Fluid accumulation pushes 
backward. 


n 
O 3 

&<. 

3 

■ST 

Sere 
c n 
2.o* 

3 

n> 

* P* 

p 

3 

a 


03 

q< 

n 2 

»*» 

If 

-d 2. 
B.S 

3 w 

5" 
w 

p 
3 
0. 

3" 


2 


? 

&" 

5' 

3 

3' 

2. 
5" 
n 


n 

CFQ 

c 
15" 

c? 
-1 

3 


Fluctuant in time. 


Unilateral, rarely bilateral. 


Paranephric Absckss. 



298 CYSTS AND TUMORS. 

Neoplasms of the retro-peritoneal glands are more centrally 
placed and quite immovable. In some cases the differentia- 
tion is impossible. 

The diagnosis is important in the case of the left kidney. 
In general we find the descending colon pushed forward by 
the tumor and lying between it and the abdominal wall. Al- 
most all larger tumors of the kidney displace the diaphragm 
up but the neighboring organs laterally. By making a gentle 
thrust in the renal region it is sometimes possible to feel the 
tumor strike the abdominal wall (renal ballottement). 

Effects. — Not rarely it may cause displacement of the liver, 
stomach, spleen and intestines. There may be rupture of the 
kidney, with external fistula or peritonitis as a result. Hypo- 
static oedema may follow rupture into the blood-vessels. 
Neuralgia or paralysis of one lower extremity may result 
from pressure on adjacent nerves. Spinal pressure paralysis 
may result from penetration of the vertebral canal through 
the intervertebral foramina. 

Prognosis. — In unilateral sarcomatous disease extirpation 
of the affected kidney has relieved symptoms and prolonged 
life. When both kidneys are affected, death is usual in a year 
or two after recognition. 

In children the disease is fatal in from ten weeks to a year. 
In adults from five months to seven years ; on an average in 
two and a half years. 

As a rule the disease lasts but a few months, rarely over 
two years. Death from carcinomatous marasmus not uncom- 
monly takes place in a year. 

Causes of Death. — These are as follows : 

i. Prolonged cachexia. 

2. Gangrene in the tumor, resulting from fistulae between 
growth and intestine or surface of body. 

3. Haemorrhage from rupture of vessels near the surface of 
the tumor, either into the urinary tract or peritoneal cavity. 

Operative Treatment. — In carcinoma excision is justifiable 



MALIGNANT DISEASE IN GENERAL. 299 

only in very rare cases, where the diagnosis is made unusually 
early. 

Even in sarcomatous cases duration of life beyond three 
years is unusual. 

Primary nephrectomy is indicated in cases of malignant 
growth. The mortality in eight years has been extraordi- 
narily diminished, as a rule — from 61.22 to 24.40 per cent. 
Those who remain free from recurrence for two years may be 
regarded as cured, though recurrence has been known after 
three years. The only hope is, therefore, in early nephrec- 
tomy. 

General Treatment. — The tumor may be prevented from 
dragging by use of a flannel roller. 

Constipation is to be overcome by appropriate means. 

Clots and coagula are to be removed by gently washing out 
the bladder. 

The pain is to be quieted by application of liniments con- 
taining Aconite or Belladonna, or by a mixture of Chloral 
hydrate and Camphor. 

As a rule. Morphine must be administered when pain is 
severe. 

Hsematuria, if profuse, requires complete rest, cold applica- 
tions to the abdomen, administration of Hamamelis, Ergot, 
Ipecac, Millefolium, Thlaspi in 30-drop doses of the tincture, 
Gallic acid in 2 to 10-grain doses, or solution Adrenalin chlo- 
ride 1:1000 in normal salt, 5' to 30 minims internally ; also 
suprarenal liquid with Chloretone (0.8 per cent. Chloretone), 
5 to 30 minims, with syrup or wine. 

In general the treatment consists in sustaining the patient 
with a nutritious diet, and in administering narcotics and styp- 
tics. Arsenicum is often indicated symptomatically and may 
relieve some of the distressing Hypernephroma symptoms. 

HYPERNEPHROMA. 

Grawitz has shown the astonishing frequency with which 



300 CYSTS AND TUMORS. 

portions of the supra-renal tissue are found under the true 
renal capsule. This aberrant adrenal tissue may give rise 
either to simple hyperplastic or to malignant neoplasms, 
which correspond in structure to the adrenal cortex, especially 
the zona fasciculata, but with less regular trabecular. The 
tumors are extremely vascular and haemorrhages into them 
are common. They are distinctly encapsulated and may 
cause metastasis into the lungs, liver, bone, etc. If malig- 
nant, the primary focus may be very small and the metas- 
tasis enormous in proportion. Their growth as a rule is slow 
and, unless transmission along the veins has occurred, they 
give rise to but few clinical symptoms. Owing to their vas- 
cular character all that may be found will in some cases be 
merely a large cyst containing blood. 

Etiology. — They occur in persons thirty-seven to sixty 
years of age, more frequently in men than in women. 

Pathologic Anatomy. — They vary in size, but rarely they 
are very large, reniform, and compress or destroy the greater 
part of the kidney substance. On section they are whitish or 
yellowish. Glycogen is found in them and also lecithin. 

In the case of a tumor of this nature removed by L,. Iv. Mc- 
Arthur, of Chicago, the following were the findings : 

Extirpated kidney, size of a cocoanut. 

The anterior surface shows only toward the hilum and up- 
per and lower poles a resemblance to the normal external ap- 
pearance of a kidney. The remainder is occupied by an 
irregular, nodular tumor, a portion of which is broken down 
and the capsule torn off. The nodules extend as much as 
one-half inch above the niveau of the external surface ; on 
section they are yellowish in color and are continuous with 
the main tumor mass to be described. 

On the posterior surface the appearance resembles more 
nearly the external appearance of the kidney, the lower por- 
tion yellowish, the upper mottled red and yellow. There are 
only two such nodules visible as are described on the anterior 



HYPERNEPHROMA. 301 

surface, which are present along the convexity. One of these 
projects three-quarters of an inch beyond the niveau, about 
the size of a walnut, and on section it seems to be- continuous 
with the main tumor-mass. The other is about the size of a 
bean ; on section it is seen to be distinctly encapsulated ; it 
contains one small cyst and some yellowish pigmented masses, 
and is distinctly separated from the surrounding cortical tissue 
of the upper pole at which both are situated. About the 
middle of the posterior surface is a cyst in the cortex project- 
ing slightly above the niveau. It was ruptured during the 
operation and looks like a simple retention-cyst. Section of 
the kidney in median line shows that a tumor more or less 
circular in form occupies the center of the kidney. The di- 
mensions of the sections are 7^x9 inches. The tumor is 
distinctly encapsulated ; toward the posterior surface it has 
caused an atrophy of the renal tissue to such an extent that 
that which remains varies in width from a mere connective- 
tissue capsule over the middle of the convexity, about one-six- 
teenth -of an inch in thickness, to one-fourth of an inch at the 
hilum. 

In the anterior half there is no trace of kidney -tissue over 
the tumor. 

At the upper and lower poles, there remain portions of 
renal tissue ; in these the relation of cortex to medulla ap- 
pears normal, is extremely firm, with well-marked glomeruli. 

The tumor itself is distinctly encapsulated, easily separated 
from upper and lower poles of renal tissue, shows toward the 
periphery, in what are apparently recent areas, a yellowish, 
more or less homogeneous structure, the nodules varying in 
size from a pea to a walnut, each separated from the other by 
septa, which arise from the tumor capsule. In one of the 
older areas is seen a distinct cyst the size of a bean ; others 
show a trabeculated appearance, in the meshes of which is 
dark, clotted blood. 

About the center of the tumor there is an area the size of a 



302 CYSTS AND TUMORS. 

half-dollar, pale yellowish in color, soft, broken down, evi- 
dently necrotic. The tumor also occupies the entire pelvis of 
the kidney, the only portion remaining of the same being a 
narrow channel at the upper and lower borders of the kidney 
about the size of an ordinary ureter, which join each other at 
the hilum, and which apparently collected the urine from the 
still intact upper and lower poles. The tumor does not ex- 
tend into the ureter, apparently having pushed the pelvis 
before it in its growth. 

The microscopic examination of sections stained with Dela- 
field's hematoxylin and eosin shows (i) in the youngest, most 
rapidly growing portions of the tumor large, clear, polyhedral 
cells ; in many the protoplasm is replaced by one or more 
large vacuoles which represent fat (washed out by the alcohol 
in the process of preparing sections). Many of the nuclei 
have been pushed to the edges of the cell by the fat contained 
therein. The cells are more or less regularly arranged in col- 
umns, which are separated from each other by delicate septa 
of connective tissue, which passes between the individual 
cells, thus forming a fine reticulum in which they lie. In 
many places, instead of the solid septa, one sees fine capil- 
laries separating the columns. There seems to be no regu- 
larity as to the distribution of the vessels. In some parts they 
are separated from each other by double layers of cells ; in 
others by larger clusters. Along many of the septa, especially 
those which are formed by vessels, there is considerable fiee 
blood-pigment. 

This small growth, just described, is completely encapsu- 
lated. The capsule at no place shows any openings through 
which renal tissue has grown into the tumor as described by 
Ricker. The connective tissue of the capsule is directly con- 
tinuous with that of the adjacent kidney stroma. The renal 
structures immediately around it show the effects of compres- 
sion with consequent atrophy of glomeruli and tubules. Fur- 
ther away the parenchyma shows a moderate degree of inter- 



HYPERNEPHROMA. 303 

stitial change. The intertubular connective tissue and that 
of Bowman's capsule show a distinct increase. The tumor 
itself bears a striking resemblance to the stratum fasciculare 
of the normal adrenal. 

In slightly older portions of the growth, e.g., the yellowish 
areas at the edge of the tumor, the cells show less vacuolation, 
the clusters of cells are much larger than in the portion just 
described. In places the cells are so closely packed together 
and irregularly placed with relation to each other and to the 
blood-vessels that the picture reminds one greatly of a sar- 
coma. According to Beneke, such a change was observed by 
him in one case in this class of tumors. I do not believe that 
one could say that such a change had occurred in our tumor, 
but that rather through rapid growth there was no longer any 
resemblance to the structure of the adrenal cortex in such 
portions. Here and there one sees cells with spindle-shaped 
nuclei which look like non-striated muscle fibers. 

A section, in which the haemorrhages can be seen with the 
naked eye, shows microscopically cavities which have no 
walls, but seem to be spaces between cells of the above de- 
scribed type and arrangement, and which have been produced 
by mechanical separation of the cell-groups. In these older 
portions there are cross sections of large blood-vessels, and the 
cells seem to rise from the vessel-wall. 

Such pictures may have given rise to the description of 
some of these growths as perivascular sarcomas, if their origin 
from aberrant renal tissue is not followed from more distinct 
fields. 

Tests for glycogen were made according to the iodin 
method, and resulted positively. The method was as follows : 
Lugol's solution, 5 to 10 minims ; dehydrate in one part tinc- 
ture iodin and 3 to 4 parts absolute alcohol. Clear in oleum 
origanum cretici. Mount in oil. The glycogen is distinctly 
seen in the form of small granules and more amorphous larger 
bodies of a deep brownish color. {Phila. Med. Journal.) 



304 CYSTS AND TUMORS. 

Pathologic Histology. — The tumor is composed of stroma 
and of cells ; proper staining reveals the presence of glycogen ; 
whether they are carcinoma or sarcoma cannot be decided. 

The urine in malignant hypernephroma shows no charac- 
teristic feature except hematuria. 

Clinical Features. — These may be almost none. In the 
case reported by McArthur and Eisendrath, of Chicago, the 
features were pain of a dull character for six years, occasional 
hsematuria for two years, and but mild cachexia. The right 
kidney was doubtfully palpable and there was some hyper- 
sensitiveness over that side as compared with the left. Other- 
wise the physical examination was negative. Operation for 
stone found none, but revealed a peculiar capsular pigmenta- 
tion and thickening. Following the operation the tumor 
grew in the cicatrix, and later the whole right kidney had to 
be removed. 

Croftan has discovered that tissue of hypernephroma de- 
colorizes the blue obtained with starch and iodine. 



CHAPTER XIII. 

TUBERCULOSIS OF THE KIDNEY. 

We shall first consider the classification and pathology of 
the different varieties, then the diagnostic and therapeutic 
features. 

Classification and Pathology. — Senn's classification is as 
follows : 

i. Miliary tuberculosis. 

2. Caseous nephritis. 

3. Tubercular pyelo-nephritis. 

Miliary tuberculosis is usually the result of general tuber- 
culosis, and commonly affects both organs at once. It may 
be associated with a like affection of the bladder, prostate or 
testicles, without symptoms which are especially renal. 

It is manifested by the presence of few or many minute, 
gray, more or less opaque tubercles surrounded by an injected 
border, more abundant in the cortex, and readily observed on 
removal of the capsule. On section linear clusters of tuber- 
cles are often to be seen continued towards the pyramids. 

Occasionally by coalescence larger nodules are produced, 
which may present a caseous center. 

Microscopically the tubercles are in some cases of the typi- 
cal form and rather sharply demarcated ; in others they appear 
more diffuse, with a partly degenerated center. The tubules 
in the immediate neighborhood show cloudy swelling. 

Caseous nephritis, known also as scrofulous kidney, renal 
phthisis, chronic renal tuberculosis and nephro-phthisis, is 
located in the substance of the kidney. It may be unilateral, 
or both kidneys may be affected. When unilateral, the right 
kidney is usually the one involved. The disorder is some- 
times primary. 
20 



306 



TUBERCULOSIS OF THE KIDNEY. 



The disease manifests itself by the extension of cheesy 
masses from the apices of the Malpighian pyramids upward 
into the cortex. At the periphery of these cheesy portions 
miliary and agglomerated gray and cheesy tubercles are to be 
seen. Microscopically we find the tubules filled with necrotic 
epithelium and large numbers of the tubercle bacilli. The 
interstitial tissue is likewise infiltrated with cells, and is ne- 




Fig. 2r. — Renal tuberculosis. — (From Roberts.) 

erotic. Unaffected portions of the kidney become invaded by 
the bacilli, either along the tubules or by entrance of the 
bacilli into the lymphatics or blood-vessels. The apices of 
the pyramids become softened as the disease progresses, and a 
series of cavities are formed, continuous with the renal pelvis. 
Post mortem we find the kidney usually enlarged unless it 
be previously contracted or fibroid. It usually gives a sensa- 



TUBERCULOSIS OF THE KIDNEY. 307 

tion of fluctuation, or has a doughy or mushy feel, and shows 
division into larger lobes or is bossellated. The capsule is 
usually much thickened and not easily stripped about the 
elevations. There may also be dense adhesion between the 
capsule and the pararenal fatty tissue. On section the kidney 
appears sacculated, and in advanced cases the intervening 
septa of normal tissue become more and more narrow, and 
the kidney may be merely a fibrous bag filled with liquid 
and curds, or both walls may become infiltrated with lime 
salts to such a degree that a calcareous shell is formed, inclos- 
ing a mortar-like material. More commonly we find the kid- 
ney enlarged, forming usually a symmetrical tumor. 

Results of the Process. — Together with the advancement of 
the process in the kidney the mucous membrane of the renal 
pelvis, ureter and bladder is affected, and both pelvis and 
ureter frequently undergo extreme dilatation. Paranephric 
abscess may also result from extension. Not rarely neighbor- 
ing lymph glands are infected. 

Amyloid kidney is not infrequently associated with uni- 
lateral caseous nephritis. 

Caseous nephritis, or chronic tuberculosis, is probably more 
frequently descending than ascending. In the case of chil- 
dren Israel found one-third of all cases of pyogenic processes 
in the kidney tuberculous, and one-fourth of these primary. 
In the case of adults Riesman holds that these figures would 
be too high, yet claims that the kidney is more often 
the starting point of congenital tuberculosis than the lower 
genito-urinary tract. Disease of one kidney may lead to in- 
fection of the other through the circulation, or through infec- 
tion via the bladder to the unaffected kidney. 

At times one kidney is found to be destroyed, while the 
other is free from the disease. 

Tubercular pyelo-nephritis is due (a), in rare cases, to es- 
cape of the contents of a primary tubercular focus in the kid- 
ney into the pelvis ; mere commonly (U) to rupture of a tuber- 



308 TUBERCULOSIS OF THE KIDNEY. 

cular abscess from adjacent organs, or (c) to ascending tuber- 
cular infection from below. Paranephric abscess is a frequent 
complication. 

Etiology. — Miliary tuberculosis is far more common than 
caseous, and nearly always secondary to general miliary tuber- 
culosis, occasionally to cases of extensive chronic pulmonary 
tuberculosis without general tuberculosis. It is possible that 
there is a primary miliary tuberculosis of the kidney, or at 
least one not secondary to general or advanced pulmonary 
disease. 

For the production of tuberculosis the essentials are as 
follows : 

i. Susceptibility of the kidney to tubercular infection. 

2. Presence in the organ of tubercular bacilli sufficient in 
number and virulence to produce their specific pathological 
effect. 

Clinically we find the following causes most common : 

i. Antecedent inflammatory conditions, especially in the 
pelvis of the kidney. 

2. Trauma. 

By preference the disease attacks males from twenty to 
forty years of age, but children are not exempt. Puny adults 
are liable to it. 

According to some authorities the disease is, on the whole, 
a rare one. 

Onset. — In some cases the disease may appear with the 
urinary features of acute hsemorrhagic nephritis, namely, 
blood, casts and more albumin than the blood accounts for. 
The writer has seen one such a case in which, however, the 
urinary condition was preceded for months by an evening 
rise in temperature. In other cases the onset is like that of 
a chronic vesical catarrh. Such a condition otherwise unac- 
counted for in children is a suspicious sign. 

Early Evidences of the Disease. — Ascending tuberculosis 
may be preceded by symptoms of chronic inflammation of the 
lower urinary tract. 



TUBERCULOSIS OF THE KIDNEY. 309 

When renal or vesical symptoms appear in a patient with 
pulmonary or genital tuberculosis, suspect urinary tuber- 
culosis. 

When persistent cystitis exists without discoverable cause, 
suspect urinary tuberculosis. 

Renal symptoms rarely appear before signs of trouble in 
bladder or prostate. 

In supposed primary renal tuberculosis extension to the 
ureter, bladder and lower urinary tract is strong, if not posi- 
tive, proof of the tubercular character of the disease, rather 
than presence of calculous disease, for example. 

The prostate is often affected before the kidneys, and, as a 
rule, the testicle or epididymis first of all. 

Cases, however, have been known in which pale urine, 
containing albumin and casts, preceded signs of trouble in 
testicle or prostate. 

The first symptoms are usually loss of appetite and weight, 
fever with evening rise, and perhaps night-sweats with poly- 
uria, and frequency of micturition, especially at night. 

Diagnosis and Clinical Features. — There are no pathogno- 
monic symptoms. The essentials for diagnosis are the pres- 
ence of a palpable swelling, and the presence in the urine of 
tubercular products. 

i. The first symptom is sometimes hceniaturia, which may 
be profuse, but, as a rule, haemorrhage is less frequent in the 
tuberculous than in the calculous disease. 

The haemorrhages may take place any time, even at night. 

The blood may first appear in clots or streaks or may be 
intimately mixed with the urine. (See also Onset.) 

2. Pain radiating from the flank into the bladder, some- 
times simulating an attack of renal colic. It is a late 
symptom. 

Pain may be absent or slight in acute miliary tuberculosis 
and in chronic tubercular nephritis. Distressing when tuber- 
cular foci rupture into the pelvis, and when there is pyelo- 



310 TUBERCULOSIS OF THE KIDNEY. 

nephritis caused by ascending tubercular nephritis. Due to 
obstruction to the free flow of urine and to presence of tuber- 
cular products. Is severe, paroxysmal and follows ureter 
down to the lower urinary tract, even to the meatus and 
testicle, which may retract. May suggest the presence of 
stone in the bladder. In some cases the pain may be slight 
and dull in the lumbar region. Sometimes it is felt in the 
inner side of the thigh. 

If the kidney is palpable, tenderness is always present, and 
the pain due to pressure often extends to bladder and urethra. 

The pain depends on involvement of pelvis or ureter, 
though if the kidney parenchyma is involved alone there may 
be a dragging sensation. As a rule the pain is uninfluenced 
by motion, but is quieted by the dorsal decubitus. It may be 
aggravated by meals, or a blow or cold, but chiefly before the 
monthly period. It may be sharp, simulating stone, possibly 
from the excretion of purulent lumps or phosphatic concre- 
tions, or from renal congestion. 

3. Associated with the pain is dysnria, tenesmus and con- 
stant desire to urinate. 

Strangury may be present, even when vesical tuberculosis 
is absent. It may suggest presence of stone in the bladder, 
hence occasion frequent sounding for stone, which in this case 
is dangerous on account of likelihood of causing mixed in- 
fection. 

4. Eventually a resistant swelling, apparently a symmetri- 
cal enlargement in the region of one or both kidneys. 

In advanced cases there is enlargement of the kidney, 
which may be associated with attacks of renal colic from pass- 
age of cheesy masses, and paroxysmal hydronephrosis if the 
ureter is blocked by these masses. 

5. More or less elevation of temperature is usually present, 
and the general symptoms of chronic tuberculosis, namely, 
irregular fever, night-sweats, progressive emaciation ancl de- 
bility are evident. 



TUBERCULOSIS OF THE KIDNEY. 311 

Not rarely chilliness or even chills may be present, fever, 
vomiting and symptoms of urinary septicaemia. 

6. The presence of tubercular products in the urine. 

Examination of the Patient. — In those cases in which we 
suspect renal tuberculosis, examine the testicles, and the pros- 
tate and seminal vesicles, by having the applicant bend over 
a chair or lying on a surgical table w T ith the thighs well flexed, 
introduce the finger into the rectum and palpate the prostate 
and seminal vesicles. These usually reveal hard nodules. 

The Urine. — i. Acid urine containing at first blood, then 
pus and albumin. Pus increases as disease progresses. 

2. The sediment contains pus and cheesy masses insoluble 
in acids and by heat. Tubercle bacilli are found in some 
cases, especially when the ureters are catheterized. 

3. To find tubercle bacilli repeated examinations of the 
urine may be necessary, with use of centrifuge, especially if 
sediment is scanty. A large amount of urine should be ex- 
amined. 

4. To distinguish the tubercle bacillus from the smegma 
bacillus use alcohol, which immediately decolorizes the stained 
smegma bacillus, while the bacillus of tubercle retains its 
stain when exposed for several minutes. 

Staining of the Bacilli. — Smear the sediment in a thin 
layer on the cover-glass, dry, float film downward in anilin 
magenta or gentian violet, rinse with a 25 per cent, solution 
of nitric acid, wash off in distilled water, float slide film 
downward in methyl blue. The bacilli appear red in a blue 
field. 

The stain used in Trudeau's laboratory is carbol-fuchsin, 
which, when washed and dried, is decolorized with twenty- 
five per cent, nitric acid, washed and dried, and placed for 
two minutes in ninety-five per cent, alcohol. 

The bacilli are differentiated with such difficulty from the 
smegma bacillus, even with acid alcohol, that guinea-pig 
inoculation is the method of choice for diagnosis. 



312 TUBERCULOSIS OF THE KIDNEY. 

George F. Laidlaw, of New York, uses the following 
method for detection of the Bacillus tuberculosis: 
i. Collect the urine for twenty-four hours. 

2. Let stand for three to six hours. 

3. Collect the sediment by use of a Purdy electric centri- 
fuge, using four tubes if necessary. 

4. Get rid of urates, phosphates, oxalate of calcium, pus and 
blood, if necessary, by measures described below. 

5. Spread the sediment on a slide without cover-glass, and 
let it dry thoroughly in the air. 

6. Holding the slide with a wooden clip fix the film by 
passing slowly over the Bunsen flame three times. 

7. Cover the hot slide with carbol-fuchsin solution and let 
it simmer for two minutes. 

8. Pour off the fuchsin and immerse the slide in clean 
water for two minutes. 

9. Drop the slide in 20 per cent, nitric acid until it loses 
all its red color, which will usually happen in from twenty to 
thirty seconds. 

10. Immerse again in the water to wash off excess of acid. 

11. Cover the slide with absolute alcohol for three success- 
ive times, of one-half minute each. 

12. Immerse again in water to wash off the alcohol. 

13. Cover the slide with a one per cent, aqueous solution of 
methylene blue for one minute. 

14. Wash off the blue in water, dry the slide in air or 
flame, place a drop of immersion oil on the dried film, lower 
the immersion lens into it and search for the bacillus. 

The tubercle bacilli appear as red rods, straight or slightly 
curved, and sometimes beaded. The color is a light or dark 
red, according to the intensity of the staining. In the urine 
they are often found in dense groups. 

Crystals of fuchsin resemble bacilli in form, and often re- 
tain their red color in spite of the nitric acid. On slowly 
changing the focus of the lens, the fuchsin crystal presents a 



DETECTION OF TUBERCLE BACILLI. 313 

middle streak of yellow with thin black borders. The tuber- 
cle bacilli are solid red with any focus. The broken edge of 
a large air-bubble or forked cracks in the film may imitate 
bacilli closely, as they often present a red color, especially 
when the decolorization with acid is imperfectly carried out. 
They can be recognized by following along the line of the 
bubble or crack. It is unsafe to diagnose anything as a 
tubercle bacillus which lies exactly on this line. One must 
search further for more conclusive forms. (Xaidlaw). 

The search for tubercle bacilli is more likely to be success- 
ful in earlier stages, before secondary infection takes place. 
It is frequently difficult to find them iu later stages, even 
when the general features of the case are well marked. 

Laidlaw very cleverly gets rid of interference from various 
urinary constituents, as follows : 

"If the urine is cloudy with urates, they must be dissolved 
by warming the sediment in a beaker, keeping below the 
point of boiling. Centrifugalize in a warm tube and spread 
on a warm slide. After this no precaution is necessary, as 
any precipitate of urates on the slide will be washed away by 
the staining fluids. 

" The interference of phosphates must be managed by dis- 
solving with five drops or so of acetic acid to one-half ounce 
of sediment. 

u Uric acid is seldom abundant enough to interfere with the 
precipitation of the bacilli. When abundant it is not annoy- 
ing, as the heavy uric acid crystals go quickly to the bottom 
of the tube, while the lighter corpuscles and bacilli rest above 
them. 

"When abundant, oxalate of lime presents an obstacle. 
Solvents of the oxalate may destroy the bacilli. The best 
plan is to spread on the two slides a thick layer of sediment, 
oxalates and all. When they are dry, rub them together to 
thin down the film, and the heating over the flame will do 
the rest. 



314 TUBERCULOSIS OF THE KIDNEY. 

" Pus is the most troublesome sediment to manage. When 
abundant it fills up the centrifugal tubes, and the bacilli do 
not readily precipitate through it. For this difficulty I de- 
vised the following manipulation : To the pus add one-fourth 
of its volume of liquor potassae and warm gently in a beaker, 
agitating it. 

u The pus will coagulate and then slowly liquefy. Precipi- 
tation at the highest attainable speed will bring down a soft, 
bulky sediment, at the bottom of which the bacilli will be 
found. On several occasions I have had the satisfaction of 
finding the bacilli with this method after they had been 
sought in vain by other examiners, and where the accuracy 
of the diagnosis was confirmed by operation and inspection of 
the tubercular areas. It is to be remembered that too strong 
an alkali will destroy the bacilli, and it is sometimes impossi- 
ble to find them in strongly alkaline, gelatinized, tubercular 
pus. I have determined by experiment that they resist the 
action of liquor potassae in equal volume, and also one-sixth 
volume of a 40 per cent, solution of sodium hydrate, and one- 
sixth volume of aqua ammonia. In purulent urines I invari- 
ably examine the sediment before treatment with potash, as 
well as after. 

" Treat bloody urine in the same way as the purulent." 

Dr. Charles Adams, of Chicago, says : " The presence of 
tubercle bacilli in the urine is not always positive evidence 
of the existence of tuberculosis of the urinary organs, as they 
are often passed from other diseased organs out of the circula- 
tion by the kidneys. In the face of clinical evidence of in- 
fection of the urinary organs, failure of the bacteriological 
test is not to be taken as conclusive ; in such cases urine- 
inoculation upon animals should be tried. Clinical evidence 
and bacteriological or inoculation tests having shown the 
existence of a tubercular lesion of the urinary tract, the all- 
important question then arises of location of the lesion. 
Modern diagnostic methods have facilitated wonderfully the 



COURSE, DIAGNOSIS, PROGNOSIS. 315 

examination of the urinary organs. With the electro-cysto- 
scope the interior of the bladder can be inspected, the stream 
of urine seen as it issues from the urethral openings in the 
bladder, and the ureters themselves catheterized. In the 
female the ureters may be catheterized by the methods of 
Simon, Pawlik or Kelly. In either male or female, the urine 
may be collected from the ureters separately by the method 
lately introduced by Harris, which accomplishes practically 
what is done by catheterization of the ureters with a simple 
apparatus such as can be used by any one possessed of any 
surgical dexterity." 

Course. — The course is sometimes erratic. Exacerbations 
may occur, with moderate pain and hsematuria, then all 
symptoms disappear until the next attack. 

In many cases the order of symptoms is as follows : Back- 
ache, haematuria and albuminuria without casts ; then putrid, 
alkaline urine ; later, swelling, pyuria, suppression of urine, 
and death. 

The disease may remain stationary for several years. 

Differential Diagnosis. — In renal tuberculosis pyuria is 
constant when the ureter is not obstructed, and intermittent 
in partial obstruction, while hsematuria is seldom profuse. In 
calculous pyelitis hsematuria is profuse and pyuria inter- 
mittent. 

The diagnosis of renal tuberculosis is generally unsatis- 
factory, unless there is a palpable swelling and the products 
of tuberculosis are found in the urine. 

In the absence of palpable swelling and tubercular products 
in the urine the table on the next page should be considered. 

Prognosis. — Always grave. If bilateral, death usually in a 
short time — one to three years after recognition. In primary 
cases life is seldom prolonged beyond two or three years, and 
in secondary cases death takes place much sooner. In uni- 
lateral cases the prognosis is unfavorable if the disease ex- 
tends to the ureter, bladder or urethra. In rare cases recovery 



316 



TUBERCULOSIS OF THE KIDNEY. 



DIFFERENTIAE DIAGNOSIS IN RENAL TUBERCULOSIS, CALCU- 
* LOUS PYELITIS AND RENAL CANCER. 



Renal Tuberculosis. 


Calculous Pyelitis. 


Renal Cancer. 


Pus in the urine abundant, 
early and continuous. Great 
quantities of vibriones and 
micrococci. Pyuria inter- 
mittent only in obstruction. 


Pus in the urine in 

small quantities at first, 
slowly increasing. Pre- 
ceded by mucus. Pyuria 
intermittent. 


Little or no pus or debris. 


Hsematuria not frequent, 
slight, and in night urine as 
well as day. Frequently ab- 
sent for long intervals. 


Occasional attacks of 
slight, sometimes severe, 
hsematuria, after exer- 
cise none at night, or 
after repose. 


Hsematuria usually light at 
first, butlaterprofuse. Spon- 
taneous, continuous, aggra- 
vated at intervals; and both 
after repose and exercise. 


Pain.— Greatest in bladder, 
relieved when bladder is 
empty. 


Pain. — Paroxysmal and 
radiating. Worse on mo- 
tion. 


Pain not affected by move- 
ments. 


Pyrexia more or less 
marked. 


Pyrexia not marked. 


Pyrexia not marked. 


Emaciation, loss uf appe- 
tite, etc. 


General nutrition good. 


L,oss of flesh, anaemia, ca- 
chexia. 



takes place in unilateral cases when lower urinary tract es- 
capes, or when the disease is encapsulated and the cheesy 
matter becomes inspissated or calcareous. Complication with 
paranephric abscess usually hastens death. 

Death is due to exhaustion and urinary septicaemia. 

Complications. — Hydronephrosis and pyonephrosis, in uni- 
lateral cases amyloid kidney ; general miliary tuberculosis. 
There may be rupture of the kidney followed by paranephritis 
or perinephritis ; fistula of the kidney or of the renal pelvis 
may occur, and perforative peritonitis. The passage of tuber- 
culous urine into the bladder causes vesical catarrh. 

Treatment. — If disease is unilateral and of small area, lum- 
bar incision may give great relief. Of late years extirpation 
of the affected kidney in unilateral disease has been followed 
repeatedly by recovery, nephrectomy being performed when 
the disease covers a large area. 

If the bladder is extensively affected, cystotomy may in 
some cases prolong life. 



TREATMENT OF TUBERCULOSIS OF THE KIDNEY. 317 

In older cases and in bilateral ones, or with invasion of 
ureters and bladder, medical treatment alone must be relied 
on. The diet is to be nutritious and digestible, but milk is 
the feature. 

Catheterization, sounding and washing out the bladder are 
contra-indicated. 

The drugs to be used are as follows : A good egg emulsion 
of cod-liver oil, and, if the stomach tolerates it, the guaiacol 
carbonate, as in pulmonary tuberculosis. 

For vesical distress, ammonium or lithium benzoate and 
salol. 

When urine is alkaline and pyuria marked, and both appe- 
tite and digestion are poor, Nux vomica, Nitric acid, Nitro- 
muriatic acid may be useful. 

In cases where there is much pus in the urine lime-water 
may be given, one tablespoonful in a cup of milk, two or 
three times daily. 

Symptomatic Treatment. — The principal remedies are the 
Iodides (Arsenic, Calcarea, Kali), China, or Chininum sul- 
phate, the Hypophosphites, Calcarea carb., Nux vomica, 
Nitric acid, Baptisia, Kreosotum and Nitro-muriatic acid. 
Carleton also suggests Hekla lava and Bacillinum. 

Baptisia is indicated where there is a hectic suppurative 
fever, disposition to well-marked chills, followed by fever and 
sweat, but no night-sweats ; general debility, languor, loss of 
hopefulness, marked anorexia. 

Nitric acid. — Habitual looseness of the bowels, yellow com- 
plexion, morning thirst. 

China. — Copious exhausting night-sweats, especially on 
forehead, neck and chest, slightly staining the linen, not of- 
fensive, occurring the moment the patient drops to sleep. 

Calcarea carb. — Cold, clammy extremities, great chilliness, 
loss of strength and flesh, great mental depression. 

Special Therapeutic Measures. — For strangury, sitz-baths 
and rectal suppositories of Opium, Hyoscyamus, Lupulin or 
Belladonna. 



318 TUBERCULOSIS OF THE KIDNEY. 

For the chills and fever, Aconite, Baptisia, China and Qui- 
nine. Iced champagne for the nausea and vomiting of threat- 
ening uraemia. When uraemia threatens, give jaborandi, as 
previously described, or use warm baths or packs, and open 
the bowels. 

Cold sponging for the pyrexia. Diarrhoea, unless patient 
is uraemic, should be checked. 

TYPICAL CASE. 

In the case of a woman which the author saw there was 
palpable swelling (tumor in the right side, lying just above a 
line drawn through the umbilicus), great sensitiveness on 
pressure, frequency of urination (but no strangury), fever, 
night-sweats and weakness. Vaginal examination revealed 
slight sensitiveness of the bladder to pressure. Examination 
of the urine revealed presence of tubercular bacilli. 

The whole twenty-four hours' urine was obtained, and the 
results were as follows : 

Quantity of urine, 750 c.c. (25 fluidounces); specific gravity, 
1.02 1 ; reaction, acid ; to talurea, 306 grains (20 grammes); 
total phos. acid, 16 grains (1 gramme); albumin, 15 per cent, 
bulk ; pus, 6 per cent. bulk. 

Sediment. — Great abundance of pus and some blood-corpus- 
cles (blood-shadows, mostly); no casts; numerous micro-organ- 
isms ; tubercular bacilli. 

The features in this examination were the high ratio of urea 
to phosphoric acid, the large amount of albumin compared 
with the pus, the absence of casts, and the presence of tuber- 
cular bacilli. Cheesy masses, insoluble in acetic acid, were 
not found. 

This case terminated fatally (without medical or surgical 
treatment, so far as I know) in about two months from the 
time that the diagnosis was made. 

In a case in which the writer examined the urine for Dr. 
McBurney, of Chicago, after removal of the diseased kidney, 



TREATMENT OF RENAL TUBERCULOSIS. 



319 



the other kidney excreted eighty fluidounces of urine in 
twenty-four hours. 

Surgical Treatment. — According to Ramsay primary renal 
tuberculosis may be classed as a semi-malignant form of in- 
flammation, and for this reason surgical treatment is always 
indicated. (2.) This surgical treatment will have a pal- 
liative or curative end in view, depending upon the condition 
of the patient and the extent of the local pathological process. 
(3.) Nephrotomy in renal tuberculous processes is to be desig- 
nated as a palliative operation, with the chief aim of the 
immediate relief of grave symptoms, it does not preclude 
a secondary nephrectomy, and coupled with free evacua- 
tion and drainage of abscesses is a most valuable pro- 
cedure. (4.) Resection of a diseased portion of a tuberculous 
kidney is a most dangerous procedure, because it is not al- 
ways possible to take out all of the disease and a focus so left 
behind may infect the other kidney or the system at large, or 
both. (5.) Nephrectomy or nephro-ureterectomy is distinctly 
indicated in every suitable case, and in suitable cases should 
result in permanent cure in 55.5 per cent, of all cases. (6.) 
The indications against nephrectomy are tuberculous disease 
of the other kidney or of other organs in the body. (7.) 
Tuberculous disease of the bladder is not to be considered a 
contraindication to nephrectomy because it will probably heal 
later. (8.) A small tuberculous focus in the lung, provided 
the patient is otherwise well, is not to be considered as a con- 
tra-indication. (9.) In cases of doubt as to whether a patient 
can stand an immediate nephrectomy, it is best to do a ne- 
phrotomy and leave the nephrectomy to a later date. (10.) 
The clamp method of managing the pedicle is contra-indicated 
on account of the danger of haemorrhage upon removing the 
clamp. (11.) It is safest to remove the ureter with the kid- 
ney, as a persistent fistula may give trouble if it be allowed 
to remain in the body. (12.) The majority of these fistulas 
tend to heal either after the removal of a deep suture or after 



320 TUBERCULOSIS OF THE KIDNEY. 

the slow disappearance of tubercular disease along the ureter, 
which then becomes a fibrous cord. (13.) We may expect an 
increasing number of cures as our means of diagnosis improve 
and our surgical technic is carried out more scientifically and 
carefully. 

In a case of unilateral primary tuberculosis in a woman 
in which nephrotomy was performed by Adams, ureteral 
irrigation with weak solutions of Formalin and Iodine was 
used after operation, and perfect recovery took place. 



CHAPTER XIV. 

DISEASES OF THE RENAL PELVIS. 

We find the renal pelvis subject to the following : 

1. Malformation. 

2. Dilatation. 

3. Hyperaemia. 

4. Haemorrhage. 

5. CEdema. 

6. Inflammation. 

7. Tuberculosis. 

8. Tumors. 

9. Cysts. 

10. Calculi. 

11. Parasites. 

Malformations of the Pelvis. — The ureter and the pelvis 
may be absent, or the pelvis small or defectively formed, and 
the ureter affected by stenosis. Valve-like folds have been 
found in both, as also bending of the ureter ; the pelvis and 
ureter may each be doubled, or in some cases the ureter may 
begin in three divisions which join to form one tube, or the 
ureter may open in abnormal places — in the prostatic urethra, 
the vagina, the uterus, the female urethra, the intestine or the 
seminal vesicle. 

HYPEREMIA OF THE PELVIS. 

Active hypersemia of the mucous membrane of the renal 
pelvis and ureter is found in cases where irritants are elimi- 
nated in the urine and also in inflammations. 

Passive hyperaemia occurs in thrombosis of the renal veins 
and may lead to haemorrhage. 

(Edema occurs in this and in inflammations. 
21 



1 



322 DISEASES OF THE RENAL PELVIS. 

Dilatation of the Ureter and Pelvis is caused by conditions 
interfering with the proper discharge of the urine. The 
latter accumulates and gradually distends the pelvis and 
calices causing hydronephrosis so-called. The ureter is also 
distended as far down as the obstruction. It may be partial, 
especially if the kidney has two pelves and two ureters, only 
one being affected. When the obstruction is complete, the 
term closed hydronephrosis is used, when incomplete open 
hydronephrosis. 

HYDRONEPHROSIS. 

Synonym . — N ephrohy drosis. 

Definition. — Dilatation of the kidney, its pelvis and calices, 
usually unilateral, rarely bilateral. 

Etiology. — Obstruction to the outflow of urine due to the 
following causes : 

i. Contraction of one or both ureters, unless resulting from 
inflammation, ending possibly in obliteration of the canal. 

2. Compression of the urinary tract below the pelvis, as by 
tumors. 

3. Obstruction from (a) congenital causes, as atresia, con- 
genital folds or twists, or oblique insertion of the ureters, or 
more commonly from (b) acquired causes, as inflammatory 
processes around the ureter ; displacement of the uterus ; 
uterine, ovarian or rectal tumors which compress or constrict 
the ureters; or from (c) result of causes within the urinary, 
tract, as inflammation, stricture, enlarged prostate, calculi, 
tumors, blood-clots, parasites. 

4. Miscellaneous causes : 

Masses of uric acid crystals in the ureter may cause it in 
children. Pressure upon the ureter by an over-filled rectum 
or bladder in a pelvis contracted by rickets or osteo-malacia 
may cause it. Diseases of the bladder involving the ureteral 
orifices are also a cause. Valve-like effects produced by mov- 
able mucous membrane of the pelvis when inflamed is some- 



HYDRONEPHROSIS. 323 

times a cause. It also is said to be a result of traumatism, 



but this may be really a pseudo-nephrosis, the urine being in 
the retro-peritoneal connective tissue and not in the pelvis. 

Congenital hydronephrosis is most frequently due to strict- 
ure of the ureter ; it may be due to absence of the ureter or 
urethra, or to compression by an anomalous renal artery, to 
an anomalous opening of the ureter into a valve in the ureter 
or pelvis. Congenital phimosis may produce hydronephrosis ; 
horseshoe kidney is occasionally hydronephrotic because of a 
sharp bend in the ureter. 

Hydronephrosis may also be due to peritoneal exudates. 
Congenital hydronephrosis may be an obstruction to labor ; 
it is often associated with club-foot, hare-lip, etc., and is fre- 
quently bilateral. 

Clinically we find urethral stricture, enlarged prostate, renac 
calculi and displacements of the kidney among the commonest 
causes. Landau holds that spasmodic contraction of the ureter 
is a noteworthy cause. 

Occurrence. — The disease is more common among women 
than among men, and may not be suspected during life. A 
common sequence is the following: Retroflexion or prolapsus 
of the uterus, pressure upon the ureter, hydronephrosis, chronic 
interstitial nephritis or atrophy (or pyonephrosis and pyelo- 
nephritis). Floating kidney by torsion of the ureter may 
cause hydronephrosis. It is more often acquired than con- 
genital. It develops most readily when the obstruction is 
either intermittent, or of slow development. 

An acute complete obstruction is not followed by hydro- 
nephrosis of any considerable degree, but soon leads to an 
arrest of secretion by counter-pressure (Riesman). In cases 
of slowly-developing hydronephrosis the accumulation con- 
tinues until the counter-pressure exceeds the pressure of 
secretion. 

Hydronephrosis may be bilateral. In 655 cases of acquired 
hydronephrosis Newman found 448 bilateral ; Morris found 



324 



DISEASES OF THE RENAL PELVIS. 



106 bilateral cases out of a total of 142 ; Roberts, 13 bilateral 
cases out of 20. Nevertheless it is said by some writers that 
it is more usually unilateral. The latter, however, should 
not be assumed by the surgeon in operating. 





&1G. 22. — Hydronephrosis; second stage; the kidney substance completely atrophied — 

(L,e Dentd ) 

Pathologic Anatomy. — We find a cystic tumor, the shape 
of the kidney, and in its site, composed chiefly of the dilated 



HYDRONEPHROSIS. 325 

renal pelvis and calices, the kidney more or less atrophied, 
appearing as an appendage to the pelvis. 

The interior of the sac is composed of communicating 
smaller sacs, (dilated calices), at the bottom of which are seen 
the flattened pyramids. 

The sac contents are a liquid of low specific gravity resem- 
bling the urine of chronic interstitial nephritis. In cases of 
long duration neither urea nor uric acid may be found in it. 
If there is complicating haemorrhage or inflammation, blood, 
pus, cholesterin, fat or chalky substances may be present, 
otherwise no sediment. 

In some cases the cyst appears as large as an abdominal 
tumor, containing several gallons. 

If the tumor is very large, the abdominal organs are likely 
to be displaced, and the colon may lie on the tumor or at one 
side of it. 

As the dilatation progresses, chronic fibrous (interstitial) 
nephritis arises in the kidney ; later, atrophy of the kidney. 

If the obstruction is in the ureter, the latter may become 
so dilated as to suggest that it is the small intestine. 

In advanced cases the kidney may be so altered that 
scarcely any renal tissue remains, and there is only a huge 
sac filled with fluid. 

Pathologic Histology. — In the beginning the pyramids are 
flattened from pressure, and there may even be necrosis of the 
apices ; the renal epithelium shows cloudy swelling, later 
fatty change ; many are desquamated and disappear, but there 
is usually also evidence of attempts at cell-multiplication. 
Coincidently with degenerative changes in the epithelium 
the connective tissue increases and compresses the glomeruli 
and tubules. Finally there is only a huge sac filled with 
fluid. (Riesman.) 

The Fluid in Hydronephrosis. — The liquid is of low spe- 
cific gravity, 1.002 to 1.012, and never alkaline when fresh. 
Urea may be found, though not always. A relative abun- 



326 DISEASES OF THE RENAL PELVIS. 

dance of sodium chloride is present. The neutral or acid re- 
action of the aspirated fluid is an important point when urea 
and uric acid are absent. 

Albumin is sometimes present ; epithelia from the pelvis 
and kidney are found, and sometimes red blood-corpuscles. 
In old cases the fluid may have become gelatinous. Infection 
of the fluid results in pus formation (pyonephrosis), and cho- 
lesterin-plates may then be found in a gruel-like substance. 

The fluid may amount to several liters, is urinous, but defi- 
cient, as compared with urine, in urea, chlorides and phos- 
phates. 

Varieties. — We distinguish intermittent hydronephrosis as 
one which disappears with removal of the cause of obstruc- 
tion, but recurs again with the cause, and remittent hydro- 
nephrosis in which the condition is persistent, but subject to 
increase and diminution. 

The term closed hydronephrosis is used in cases in which 
the flow of urine is completely interfered with, and open hy- 
dronephrosis when only partially. 

Diagnosis. — A fluctuating tumor in the region of the kid- 
neys, which diminishes in size when the urine increases in 
amount, points to hydronephrosis of the intermittent variety. 
A tumor persistently present, associated with obstruction to 
the free flow of urine, also suggests this disease. 

Clinical Features. — We may find some one of the follow- 
ing : 

i. Gradually forming tumor ; no symptoms, and no lesion 
recognized except post mortem. 

2. Constant, dull, dragging pain in the loin over affected 
kidney, lasting a long time, and development of fullness or 
tumor. 

3. Intermittent hydronephrosis : temporary diminution in 
quantity of urine per twenty-four hours, possibly vomiting 
and fever for a few days, followed by polyuria, possibly hsem- 
aturia, and relief. Such hydronephroses tend to re-accumu- 
late and the process may be repeated indefinitely. 



DIAGNOSIS OF HYDRONEPHROSIS. 



327 



4. Large tumor, unilateral or bilateral, filling greater part 
of abdomen ; smooth, resistant ; transmits sense of fluctuation ; 
pain extending to thigh ; persistent constipation and dyspnoea 
may accompany it. 

5. Double hydronephrosis with progressive enlargement ; 
symptoms of chronic fibrous nephritis, as chronic uraemia. 

Bilateral cases are almost always congenital and cause death 
from uraemia in a few days at most. 

Hydronephrosis in cases of movable kidney may show it- 
self by the disappearance of the tumor on passage of much 
clear urine. 

Not rarely, and especially in bilateral cases, there are 
uraemic and septic symptoms,. as chills, fever, nausea, vomit- 
ing, headache, and even convulsions. Paraplegia occurs as a 
complication in some cases. 

The Urine. — Unilateral hydronephrosis : the sound kidney 
excretes normal urine. 

Bilateral. — Normal urine until close of life, then that of 
chronic fibrous nephritis. 

In intermittent hydronephrosis a large tumor suddenly dis- 
appears with the simultaneous passage of a large quantity of 
urine. 

Differential Diagnosis. — The renal nature of tumor may be 
suspected from the seat, especially when the colon lies in front 
of it. The colon in such a case, when empty, may be felt as 
a movable cord, and can be distended by inflating the intes- 
tine. The larger the tumor the more likely the colon to be 
displaced laterally. Aspiration withdraws a fluid containing 
urea and uric acid, except in unilateral cases of long standing. 

In young children it is difficult to distinguish sarcoma of 
the kidney and enlarged retroperitoneal glands from hydro- 
nephrosis. 

Hydronephrosis is to be distinguished from ovarian cys- 
toma. The ovarian tumor is more freely movable, fills the 
lower portion of the abdomen and tends to push the intestines 



328 DISEASES OF THE RENAL PELVIS. 

upwards, while in hydronephrosis the ascending colon can 
often be made out passing over the hydronephrotic tumor. 
Aspiration may, in the case of an ovarian cyst, reveal Graafian 
cells. 

Hydronephrosis is distinguished from pyonephrosis by the 
absence of constitutional symptoms. 

In rare cases a large hydronephrosis has been mistaken for 
ascites, while the combination of movable kidney and hydro- 
nephrosis occurs. Aspiration and examination of the fluid 
may therefore be of service in doubtful cases, except w T hen the 
disease is of long standing. 

It may be difficult to distinguish hydronephrosis from hy- 
datids of the liver or kidney unless, by aspiration, the scolices 
and hooklets can be found, as in the case of hydatids. 

Course. — Acute hydronephrosis may last from a few hours 
to a few days. Chronic cases may persist for years or even 
for a life-time. 

Prognosis. — Unilateral: Produces merely mechanical dis- 
comfort. Intermittent : not essentially serious. Bilateral : if 
progressive, prognosis unfavorable, like chronic fibrous ne- 
phritis. 

In congenital cases death takes place at birth, or in a few 
months or years. 

When due to renal calculus or uterine displacement, prog- 
nosis depends on the cause. 

A majority of the cases never cause trouble. A certain 
proportion are cured by spontaneous evacuation. In some 
cases the growth of the tumor is such as to require surgical 
interference ; the same is true when infection and transforma- 
tion into pyonephrosis take place. A few cases of intra-ab- 
dominal rupture, or even evacuation through the diaphragm 
and lungs, have been reported. Rupture of the pelvis of the 
kidney occurs, but is rare. 

Usual Causes of Death. — Suppression of urine, rupture of 
the sac into the abdomen, or interference with the functions 



DIAGNOSIS OF HYDRONEPHROSIS. 329 

of other organs. Suppurative pyelo-nephritis and death may 
follow operations on the lower urinary tract when hydrone- 
phrosis is present. 

Treatment. — If due to lesions, such as displacements, renal 
calculi, etc., careful manual pressure, emptying the sac, fric- 
tion over tract of ureter or on the sac, hot baths, etc. If due 
to pelvic tumors, lower bowel to be emptied daily ; support of 
tumor as in prolapsed uterus by pessaries. If tumor rapidly 
increases and cannot be emptied by ordinary pressure, surgical 
means necessary, as tapping, nephrotomy, or nephrectomy. 
Landau thinks nephrectomy contra-indicated. Recently an- 
other mode of operating has been tried, viz., stitching the sac 
to the skin. J. K. Thornton holds that if the fluid re-accum- 
ulates after several tappings, nephrectomy is preferable to ne- 
phrotomy and drainage. 

Aspiration affords temporary relief, and by repetition some- 
times cures. The needle is to be inserted, if on the right 
side, two and a half inches behind a line perpendicular to the 
anterior superior spine of the ilium, and midway between the 
crest of the ilium and last rib. On the left side an inch 
higher up. Strict antiseptic precautions are necessary. In- 
cision and drainage are often preferable. 

Medical treatment of this disorder is practically unavailing. 
In women a carefully adapted belt and band may be used to 
prevent, recurrence. 

Congenital bilateral hydronephrosis cannot be relieved by 
treatment. Unilateral cases are sometimes tapped, but there 
is serious risk of rupturing the sac or producing peritonitis. 
In rare cases the fluid can be forced out by manipulations. 

Acquired hydronephrosis has been relieved by massage ; 
some danger attends this measure, as too much force may 
rupture the sac. 

Intermittent hydronephrosis, due to movable kidney and 
kinking of ureter, may be relieved by nephrorrhaphy. 

Nephrotomy is rarely fatal, but in more than half the cases 
produces permanent fistula. 



330 DISEASES OF THE RENAL PELVIS. 

, Nephrectomy has had a mortality of forty-one and three- 
tenths per cent. 

For hydronephrosis, which is of long standing and with ab- 
solute closure, nephrectomy is the better operation unless the 
occlusion can be relieved. Recent hydronephrosis calls for 
nephrotomy, fixation to the lumbar fascia and drainage. The 
operation is useful in intermittent hydronephrosis due to 
kinking of the ureter. 

For nephrotomy the best incision is the oblique, because it 
splits the muscles instead of cutting them. 

In nephrectomy the most convenient incision is the oblique 
one. The fatty capsule is stripped off from the kidney, the 
vessels separately ligated, and, when practicable, the ureter 
should be ligated, disinfected and dropped. The chief diffi- 
culties encountered are in dealing with the vessels and in 
avoiding cutting into the peritoneum. Nephrectomy may be 
not rarely complicated by the fact that the renal pelvis may 
adhere to the stomach or adjacent loops of the intestines. 

PYONEPHROSIS. 

Definition. — Dilatation of the pelvis of the kidney with 
urine mixed with pus. The term is also used to describe the 
condition of the kidney when, from renal abscess, it becomes 
converted into a pus-sac. 

Etiology. — That of. hydronephrosis, which has become the 
seat of suppurative inflammation. Stone, tuberculosis, injuries, 
septic inflammation, and malignant disease of neighboring or- 
gans are common causes. It is said, however, to occur, like 
pyelitis, in the course of acute nephritis, diphtheria and other 
infectious diseases. 

Careless aspiration of hydronephrosis, rupture of renal ab- 
scess, and obstruction of the ureter by tuberculous, cheesy 
masses or by blood-clots, and ascending gonorrhceal infection 
obstructing the ureter are causes. 



PYONEPHROSIS. 331 

Clinically we find impaction of stone in the pelvis a common 
cause. 

Pathologic Anatomy. — That of hydronephrosis, except that 
the sac contains pus in addition to urine, and instead of a 
smooth, shining, grayish-white wall, there is a rough, opaque- 
yellow, perhaps granular or ulcerated wall. 

Clinical Features. — Those of hydronephrosis, except that 
the tumor rarely attains so large a size. Persistent pyone- 
phrosis has the symptoms of suppurative pyelitis. Evacua- 
tion of the tumor, like that of hydronephrosis, may take place 
into the intestine, pleura or lungs. 

Aspiration will show presence of pus. 

The Urine. — In intermittent pyonephrosis the diminution 
in size of tumor is associated with presence of pus, blood and 
albumin in the urine. The presence of large amounts of fat 
in the urine has been noticed in this disorder, as well as in 
paranephritis. 

Course. — The duration of this disorder is from three 
months to several years, usually not longer than three years. 

Differential Diagnosis. — Pyonephrosis is differentiated from 
hydronephrosis by smaller size and presence of pus ; from cir- 
cumscribed peritonitis by presence of pus in the urine ; from 
solid abdominal tumors by aspiration. 

Causes of Death. — Death soon follows rupture into retro- 
peritoneal tissue, peritoneal cavity, or thorax. Death may 
follow inflammation induced in renal substance or neighbor- 
ing parts. The patient may succumb to slow, gradual ex- 
haustion and anaemia with low fever, symptoms of amyloid 
degeneration of various organs, pyaemia and septicaemia. 

Prognosis. — Unfavorable, if primary disease is tuberculosis 
of renal pelvis or bladder, or malignant disease of uterus or 
rectum. 

Unfavorable, if distension of the renal pelvis is rapid and 
due to sudden impediment in escape of pus ; the danger to 
life is in such cases great, unless surgical interference is pos- 
sible (nephrotomy or nephrectomy). 



332 DISEASES OF THE RENAL PELVIS. 

Unfavorable, if urine is alkaline and there is vesical irrita- 
tion. 

Not immediately unfavorable, if urine is acid, pus in small 
bulk in the renal pelvis, obstruction and suppuration unilat- 
eral in otherwise healthy patient. 

Pyonephrosis is essentially a chronic disorder, and the py- 
uria and hsematuria may continue over a long period of time. 

Favorable, if tumor ruptures into some part of conducting 
portion of urinary tract, and at the same time no grave struct- 
ural change has taken place in the affected kidney. 

Amelioration, if rupture takes place into alimentary canal; 
there is constant danger of acute peritonitis. 

Recovery has been known to take place when formation of 
pus ceases, and the sac contracts on a cheesy mass. 

Treatment. — Attend to cause of obstruction ; displacements 
of pelvic organs, tumors, renal calculus, urethral stricture, en- 
larged prostate, etc., must be looked for and, if possible, rem- 
edied. If the purulent discharge from the kidney is found 
intermittently in the urine, and there are signs of calculous 
obstruction, keep patient at rest on a sofa or specially con- 
structed couch and administer diluents, as distilled water, 
freely. If the urine is over -acid, give alkaline waters, corn- 
silk, lithia and 1 ' erebinthina. If alkaline, render acid with 
Boracic acid, unless the irritation is primarily due to uric 
acid as shown by history, in which case alkalies may prove 
more serviceable. If swelling increases in bulk and there is 
more pain, and pus is not freely found in the urine ; if fever, 
gastric symptoms, rigors, sweat and emaciation are noticed, 
together with evidence of extension of the inflammation, then 
surgical interference is immediately required. First, nephrot- 
omy with free antiseptic drainage at point of election behind. 
If the purulent discharge from the sinus is continuous and 
undiminishing, nephrectomy is to be performed when the 
patient has recovered from the pysemic condition. Mortality 
is lower, when there is no calculous obstruction. 



PYELITIS. 333 

Massage, with ingestion of large quantities of fluids, has, 
according to Carleton, been successful in some recent cases. 

HEMORRHAGE. 

This is due to inflammation, passive congestion, infectious 
diseases, haemorrhagic diseases, injuries, stone, parasites or 
tumors. 

PYELITIS. 

Definition. — Inflammation of the mucous membrane of the 
pelvis of the kidney. May occur without pyelo-nephritis, or 
the latter may result from it. 

Etiology. — Pyelitis is essentially a secondary disorder of 
bacterial or toxic origin. It is said that it may occur pri- 
marily, but such cases are undoubtedly rare. We find com- 
monly the following causes : 

i. Hsematogenous infection of the pelvis from diphtheria, 
typhoid fever, scarlet fever, small-pox, measles, cholera, acute 
nephritis and possibly gonorrhoea. It accompanies pyaemia, 
scurvy and enteric fever. 

2. The result of irritation due to the elimination of certain 
poisons, as copaiba, turpentine, cantharides, and cubebs. Glu- 
cose acts as an irritant also, and we find a diabetic pyelitis. 

The above causes usually produce mild cases which may 
escape notice altogether ; more severe cases may be due to the 
following : 

3. Extension of inflammation downward from the kidney- 
substance, or upward from the lower urinary tract, or rarely 
from neighboring parts. Most commonly it is due to urethri- 
tis or cystitis, sometimes to acute or chronic nephritis or 
tuberculosis of the kidney, less commonly to paranephric or 
perinephric abscess rupturing into the pelvis. 

4. Presence of some foreign body, as calculus, tumor, blood- 
clot or parasite. Obstructed ureter and sarcoma are common 
causes under this heading. 



334 DISEASES OF THE RENAL PELVIS. 

Cases thought to be primary may eventually be found due 
either to tuberculosis or stone. It is said, however, that there 
is a pyelitis due to " catching cold." 

Pyelitis is quite commonly due to extension of inflammation 
in cases where there is obstruction to the free flow of urine, as 
in stricture or enlargement of the prostate, the inflammation 
in these cases showing a marked tendency to ascend ; cystitis 
from paralysis in spinal diseases also causes ascending pyelitis. 

Any case of urethritis or cystitis, if it last long enough, may 
advance upward to the ureters and pelvis, so that in severe 
cases we often find an inflammation of the whole urinary tract, 
pyelo-cystitis so-called, and even ureteritis and suppurative ne- 
phritis at the same time. 

Pyelo-cystitis may develop in low grade genito-urinary in- 
fections from sudden relief of prolonged retention, exposure 
to cold, shock or operative trauma. Infection alone in such 
cases does not wholly account for the condition. Circulatory 
disturbances, internal blood metastasis or traumatism is neces- 
sary to virulent development. (Lydston.) 

The danger of onset of pyelitis is always great when, for 
any reason, there is urinary stasis. It is common in diseases 
of the kidney parenchyma, especially passive hyperaemia, 
acute diffuse and chronic diffuse nephritis. 

In pyelitis secondary to cystitis the ureter is often slightly 
or not at all affected, the urine in the pelvis being infected by 
the agent. The occurrence of an ascending pyelitis without 
a previous cystitis is possible. 

In acute pyelitis we find the Bacillus coli communis most 
commonly the cause. In general, pyelitis is due to the pres- 
ence in the pelvis of the kidney of an irritant, either bacterial 
or toxic. 

Cases arising from child-birth or following diseases of the 
sexual organs are likely to be due to infection from either the 
bladder or the kidneys. Cases are cited referable to constipa- 
tion merely as a cause, in which case the colon bacillus is 
thought to be the exciting cause. 



PYELITIS. 335 

Pathologic Anatomy. — The disease may affect one kidney, 

but is usually bilateral. 

There are several pathological classes of pyelitis, as follows : 
i. Catarrhal. — Swelling, thickening and injection of the 

mucous membrane, with sometimes punctate haemorrhages 

and turbid residual urine in the pelvis, containing leucocytes 

and detached epithelia. 

2. Suppurative. — Thickened, discolored, mucous membrane 
with less conspicuously injected blood-vessels, but pus is pres- 
ent in the urine in the pelvis, and the mucous membrane may 
be ulcerated. 

The pelvis is more or less distended and filled with puru- 
lent urine. Microscopically we find round-cell infiltration, 
hyperaemia and desquamation of the pelvic epithelium. In 
advanced cases (pyelo-cystitis), those due to stone or other 
causes, ulceration, gangrene and perforation may take place. 
In these cases there is usually also pyelo-nephritis. 

If nephritic abscesses burst into the pelvis, ulcers form and 
may penetrate deep into the renal tissue (pyonephrosis). 

3. Pseudo-membranous or diphtheritic. — Not rare in cases in 
which the urine contains virulent bacteria. In such cases we 
find superficial necrosis, with deposit of salt ; apices of pyra- 
mids necrotic or destroyed. 

4. Hemorrhagic. — Cases in which haemorrhages into the 
inflamed membranes occur. 

Note. — The pathological condition in the ureter and 
bladder usually corresponds to that of the pelvis, but the 
ureters may evince evidence of only catarrhal inflammation 
when both bladder and renal pelvis are affected by the other 
lesions. 

Chronic pyelitis. — We find the mucous membrane thick- 
ened and ridged ; sometimes a papillary hyperplasia occurs, 
and rarely a peculiar cyst formation ; at other times the 
mucous membrane is epidermatized and becomes horny and 
shiny, a condition termed cholesteatoma. (Riesman.) 



336 DISEASES OF THE RENAL PELVIS. 

Chronic pyelitis, with retention of urine in the pelvis and 
dilation, may result in secondary contracted kidney. 

Occurrence. — More frequent in men and in adult life. 

Clinical History. — The most common clinical history is 
that of stricture or enlargement of the prostate ; quite com- 
monly also we may find that the patient has had gonorrhceal 
cystitis or a renal calculus. The infection may be due to use 
of unclean instruments. In some cases local tuberculosis is 
the history. 

The milder forms of pyelitis are those of the acute infec- 
tious diseases, the puerperal state, from poisoning, and in mild 
cystitis. The severe forms are pyelo-cystitis and pyelo-ne- 
phritis from stricture, paralysis of the bladder in spinal dis- 
eases, and from new growths or parasites of the kidney. 

Diagnosis. — A severe disease of the urinary passages with 
fever points to pyelitis and pyelo-nephritis ; whether the py- 
elitis is unaccompanied by pyelo-nephritis may be inferred 
from the history and absence of micrococcus casts in the 
urine, together with, as a rule, less severe general symptoms. 

The diagnosis depends upon the local alterations in the 
kidney (feeling of tension, pressure, pain, or pain on pressure) 
and changes in the urine (presence of mucus or pus). 

Clinical Features. — The symptoms may be masked by 
those of the disease of which it is a complication, or before 
suppuration may be altogether insignificant. The most com- 
mon features are as follows, in the cases before suppuration : 

Dull pain in the region of one or both kidneys. 

Sensitiveness on deep pressure. 

Possibly moderately severe pain following course of one or 
both ureters. 

Usually little or no constitutional disturbance. There may 
be nocturnal transitory fever, especially during attacks of 
pain. Sometimes decided chills and sweating. Absence of 
pain does not exclude pyelitis. 

Usually the patient complains of a feeling of tension or 



PYELITIS. 337 

pressure in the region of the kidneys. Pain may be present 
and is worse on pressure. Pain may be absent, but brought 
on by pressure over the region of the kidneys. 

The urine is acid in reaction, cloudy, contains a small quan- 
tity of albumin, a few per ceut. only by bulk, and a small 
amount of pus, with a few blood-corpuscles. No casts are 
found. 

In some cases only an exaggerated mucous cloud may be 
noticed in the urine. 

When the case proceeds to suppuration the following symp- 
toms appear : 

Chills with a decided rise in temperature ; in severe cases, 
a septic temperature with very marked accessions and remis- 
sions, and repeated chills persisting ; in milder cases, a small 
evening rise, dropping to normal the next morning, especially 
in tuberculous pyelitis. 

The patient after a time is anaemic, loses flesh and strength, 
has loss of appetite, night-sweats, and a constantly elevated 
temperature. Marked remissions occur and the disease may 
last for many years. 

The urine, after suppuration is established, may contain so 
much pus as to be almost milky. In cases due to septic in- 
flammation of the lower urinary 7 tract we find small gelatin- 
ous masses in the urine composed of rod-shaped bacilli and a 
little calcium oxalate. While the freshly-voided urine may 
be acid, it soon, in standing, becomes alkaline and deposits 
triple phosphate. 

In general the urinary features of chronic pyelitis are as 
follows : 

i. Quantity increased ; polyuria. 

2. Color decreased or of a greenish tint. 

3. Odor slightly like that of rotten eggs. 

4. Solids deficient ; specific gravity diminished. 

5. Triple phosphate crystals found even in acid urine (in- 
complete forms). 

22 



338 DISEASES OF THE RENAL PELVIS. 

6. Pus present as in acute, with albumin corresponding. 
The pus-corpuscles have tooth-like projections and red blood- 
corpuscles are decomposed. 

7. Micturition may be frequent, but is usually painless. 

In cases where pyelo-cystitis leads to secondary contracted 
kidney, we may find in addition a few hyaline casts. 

See also Renal Calculus, Cancer, Tuberculosis and Cystitis 
for urinary features. 

Casts may be from the mouths of the urinary canaliculi 
(ductus papillares), which are involved in all but the milder 
cases of pyelitis. Pus casts and casts of cocci occur in septic 
cases, as in pyelo-nephritis. 

If the pyelitis is unilateral, the flow of purulent urine may 
be followed by that of a normal urine, due to temporary ob- 
struction of the ureter continuous with that of the diseased 
pelvis. Catheterization of the ureter demonstrates the exist- 
ence of such a condition. 

Downes (Philadelphia) presents a new instrument for the 
collection of the separate urines which he calls the u Separate- 
Urine Siphon." It is a modification of the Harris segregator, 
in that the suction apparatus is dispensed with, and the in- 
strument further simplified in other ways. It is made of two 
parts — a double-barrelled bifurcating catheter of small calibre 
(13 American scale), and a partition-rod which elevates the 
bladder-wall between the catheter ends for fully 2 x / 2 inches. 
The rod differs for the sexes, and is attached to the end of the 
shank of the catheter by a small fixed clamp and thumbscrew. 
Movement of the beaks during introduction of the instrument 
into the bladder is prevented by a little fixation-pin. 

In all cases where instruments are used the patient should 
rest for forty-eight hours, and take Salol in five-grain doses 
beforehand. 

In pyelo-cystitis the urine will gradually become ammoni- 
acal, and be opaque, stringy and of a dirty color, resembling 
in other features also that of cystitis. 



PYELITIS. 339 

Clinical Varieties. — The clinical features above described 
apply chiefly to acute primary, and chronic primary pyelitis. 
Other forms of the disease with their features are as follows : 

Traumatic Pyelitis. — In slight injury, few symptoms, slight 
hsematuria ; more serious cases, pyaemia and pain. The prog- 
nosis is generally favorable. Some cases may require ne- 
phrectomy. 

Neurotic Pyelitis. — Occurs in neurotic girls ; the features 
are slight lumbar pain and intermittent haematuria. Prog- 
nosis good. The disease lasts but a few days and terminates 
in recovery. 

Calculous Pyelitis. — Due to presence of one or more stones 
in the renal pelvis. It is usually a chronic condition. The 
features are, first, pyuria, which may be symptomless for 
years ; pain in the region of the kidney and enlargement of 
the kidney. More or less blood is usually found and may 
form a thin, reddish layer on top of the heavier pus sediment. 

Tubercular Pyelitis. — May be subacute in form, without 
much pain or fever. There is pale, acid urine of low specific 
gravity containing pus and albumin. In some cases tubercle 
bacilli may be found in the urine, especially in early stages. 

Ascending Pyelitis (secondary pyelitis). — Acute cases are 
due to injudicious use of instruments on the lower urinary 
tract in patients either lithsemic or tuberculous, or may result 
from the sudden removal of a hydronephrosis in cases of en- 
larged prostate. It may terminate fatally in less than ten 
days. Subacute cases may follow gonorrhoea and are seldom 
fatal. 

The clinical features in these cases are sudden rise in the 
temperature of the body, dull pain in the region of the kid- 
neys, frequent urination, or rapid suppression of urine. The 
latter is usually of acid reaction and cloudy from swarms of 
micro-organisms and pus. 

Chronic cases are essentially those of cysto-pyelitis or pyelo- 
nephritis, and occur in the case of enlarged prostate, chronic 
cystitis, spinal disease, stone or tumors. 



340 



DISEASES OF THE RENAL PELVIS. 



Differential Diagnosis. — Pyelitis is to be differentiated from 
pyelo-nephritis and from cystitis as follows : 



PYELO- NEPHRITIS. . 

Alkaliue urine. 

Absence of tenesmus ves- 
icae. 

Albumin sometimes 
abundant. 

Constitutional symptoms 
marked. 

Pain over the renal 
region. 



PYELITIS. 
Acid. 
Absence of tenesmus. 

Albumin seldom abun- 
dant. 

Constitutional symptoms 
not marked at first. 

Pain over the renal 
region. 



CYSTITIS. 
Acid or alkaline. 
Vesical tenesmus. 

Albumin seldom abun- 
dant. 

Constitutional symp- 
toms not marked. 

No pain over renal 
region. 



In chronic pyelitis there is sometimes polyuria, suggesting 
chronic interstitial nephritis, but pain over the region of one 
or the other kidney and absence of the cardio-vascular symp- 
toms serve to differentiate. 

A sharp line between pyelitis and cystitis can not always 
be drawn owing to the fact that inflammation of both renal 
pelvis and bladder may co-exist ; the same may be said of 
pyelitis and pyelo-nephritis. The above table is seldom of 
much clinical value. 

Pyelitis may sometimes be distinguished from cystitis by 
the fact that in severe cystitis the limit of the amount of al- 
bumin is o. i per cent, by weight ; in pyelitis the pus-corpus- 
cles in the urine are crenated and the red blood-corpuscles 
show evidences of decomposition. 

Pyelitis is often associated with hydronephrosis, in which 
case there is severe renal pain coming on suddenly, with 
chills, fever, vomiting and diminished amount of clear urine. 
The symptoms subside when the obstruction is relieved. 

Course. — The course is that of the primary disorder, hence 
may be acute, subacute and chronic. Pyelo-cystitis is a tedi- 
ous disease which may last for years. Chronic pyelitis is 
likely to be complicated by pyelo-nephritis, with termination 
in uraemia, urinary septicaemia, rupture or amyloid kidney. 

Prognosis. — i. Favorable, when due to bacterial poison of 



PYELITIS. 341 

infectious diseases or to toxic irritants ; except when due to 
acute nephritis, cholera or diphtheria, where prognosis is 
grave. 

2. Sei'ious, when pyelo-nephritis results, though even then 
recovery is possible. 

3. Serious, when associated with grave vesical disorders, 
owing to danger of pyelo-nephritis. 

4. Serious, when after chronic pyelitis of long duration, 
amyloid disease or chronic interstitial nephritis results. 

In general, in severe urinary diseases, when pyelo-cystitis is 
established it becomes a tedious and incurable malady. 

Pyelitis due to stone has a more favorable prognosis in a 
subject well suited to operation. 

The prognosis in chronic pyelitis is unfavorable where an 
acute pyelitis develops. 

Treatment of Pyelitis. — In general it may be said that the 
following measures should be taken : 

1. "Judicious management of any infectious fever pres- 
ent.' ' (Anders.) 

2. Removal of any inflammatory cause, including stricture 
or enlarged prostate. 

3. Rest, regulation of the diet, avoidance of sexual excess. 

4. Use of urinary antiseptics, balsams and astringents. 

5. Hot applications or plastic dressings. 

6. Free use of diluents and demulcents, as fresh butter- 
milk, boiled milk with lime-water, Vichy water, etc., etc. 

7. Avoidance of irritating diuretics and unnecessary surgi- 
cal examinations. 

8. Administration of any remedy indicated symptomati- 
cally. 

The essentials of general treatment are as follows : 

Confinement to bed in acute cases. 

Great care to be taken to avoid chilling of surface of body. 

Avoidance of sexual intercourse. 

Non-nitrogenous or largely farinaceous diet. In severe 



342 DISEASES OF THE RENAL PELVIS. 

cases absolute milk diet, as long as fever lasts. Milk diet is 
also best for the chronic suppurative or tuberculous forms. 

L/ong-continued lukewarm baths during exacerbations. 

Unless the polyuria is excessive, patient should drink very 
freely of water. French Vichy is an excellent water in py- 
elitis. 

Satterthwaite suggests that the patient sit over a steaming 
decoction made by putting a bunch of wormwood in a cham- 
ber or other receptacle in a closed water-closet-chair, and then 
pouring on it boiling-hot water. 

In severe cases where pain is a feature, application of warm 
poultices or of antiphlogistine over the region of the kidneys 
should be made. 

It goes without saying also that treatment for the primary 
inflammatory disease is indicated. Timely treatment for cys- 
titis may prevent the onset of pyelo-nephritis. 

Urethral stricture or enlarged prostate must be removed. 
If the case depend upon an infectious fever "judicious" treat- 
ment of the latter is necessary. Irritating diuretics must be 
avoided in the treatment. 

Remedies. — For palliative treatment the urinary antisep- 
tics, Salol and Urotropin, are frequently used. 

Bichhorst advises, first, the use of an antiseptic, as Salol, 
for ten days to two weeks ; then Turpentine, and finally Tan- 
nic acid. He uses the above as follows : 

Salol, fifteen grains ; Saccharin, one-third of a grain ; ten 
powders, one every two hours. Oil of Turpentine, dose, ten 
drops in milk three times daily. Tannic acid, four and a half 
grains ; Saccharin, one-third of a grain ; ten capsules, one 
every three hours. 

The writer frequently uses Urotropin instead of Salol, and 
occasionally Eucalyptol instead of Turpentine. 

Urotropin is valuable in chronic cases, especially in the 
elderly, when there is weakness, loss of appetite, pale color, 
dry, crusted tongue, thirst, and slight rise of temperature, as 



PYELITIS. 343 

in cases of chronic urinary fever due to absorption of micro- 
organic toxins or of urinary poisons. Dose, from three to 
seven and a half grains, taken first twice, later three times, 
daily in a glass of water. Increased if necessary to ten grains 
three times daily. 

The writer finds Urotropin fairly reliable. Sometimes, 
when the urine is scanty, it may with advantage be alter- 
nated with the corn-silk and lithia mixture mentioned before. 
Simple catarrhal pyelitis often subsides by treatment with 
this agent (Urotropin) and rest in bed. 

Salol is used for much the same purpose as Urotropin. It 
may be given in eight-grain doses, three to five times daily. 

Ergot is advised by Morris in doses of one-half drachm of 
the fluid extract when polyuria is a feature. 

Creasote is recommended by Dickinson in cases where the 
urine is foetid. 

Potassium citrate is suggested by Osier, who thinks that 
astringents are useless in pyelitis. 

Hydrangea is useful in calculous pyelitis due to uric acid, 
especially when combined with lithia, and the same may be 
said of Corn-silk. The writer uses a lithiated sorghum com- 
pound (corn-silk, broom-tops, lithia) with marked palliative 
effect in these cases. 

Chronic cases may require Salol, Urotropin, Sandalwood, 
Juniper, Copaiva and Erigeron as palliatives. 

Symptomatic Treatment. — Acute Pyelitis: — The principal 
remedies are Aconite, Bryonia, Belladonna, Cantharides, 
Chimaphila, Cannabis sativa, Rhus tox., Terebinthina, Uva 
ursi. 

Chronic Pyelitis : — The principal remedies are Benzoic acid, 
Berberis vulg., Buchu, Cantharis, Chimaphila, Hydrastis or 
Hydrastinum, Pareira brava, Pulsatilla, Sepia, Sulphur, Stig- 
mata maidis, Uva ursi. 

Cantharis, not lower than the third, is the remedy when 
micturition is painful and the urine contains pus and blood. 
Useful in either acute or chronic pyelitis. 



344 DISEASES OF THE RENAL PELVIS. 

Uva ursi is best adapted to acute pyelitis, and is best given, 
according to Hughes, in form of a trituration of the leaves. 
A tea made of the leaves, one tablespoonful to a large glass of 
hot water, given three or four times daily. 

Corn-silk. — Useful when the urine is scanty and acid. 
Combined with lithia is serviceable for increasing the urine 
and dissolving sediments of uric acid if present. 

Terebinthina for violent burning, tearing pain in the renal 
region, pronounced strangury, scanty, bloody urine, frequent 
micturition at night. 

If the urine is strongly acid, give also alkaline demulcent 
drinks. 

Drop doses of the oil may be given ; in some cases two to 
five minims may be necessary ; or Eucalyptol in capsules in 
the same dose. 

Mercurius is said to be indicated especially when the 
amount of pus in the urine is very large. (Use third dec- 
imal.) 

Copaiba is indicated by pain in the renal region, tenesmus, 
and hematuria with albuminuria. 

Arsenicum in the 3X trituration for the cachexia caused by 
long-lasting suppuration. Haematuria with burning pain, 
albuminuria with weakness, emaciation and oedema, colliqua- 
tive diarrhoea and hectic fever are Arsenicum symptoms. 

China is recommended by Hughes in chronic suppurative 
pyelitis. 

Silica is recommended by Jousset in high dilutions as of 
value in suppuration. 

Chimaphila (in ten-drop doses of a good fluid extract) di- 
minished the pus sediment in one of the writer's cases of 
simple pyelitis of not long standing. 

Sulphate of quiiiine is recommended (in doses of from fifteen 
to twenty-two grains) for the pernicious attacks during the 
acute period of pyelitis. It should be administered during 
the decline of the attack. 



PYELITIS. 345 

Chronic Pyelitis. — The remedies are as follows (in addition 
to those already mentioned): 

B a ros ma. —Recommended by Dr. E. M. Hale in chronic 
pyelitis. 

Benzoic acid. — After the pain and fever of the acnte stage 
have subsided, but urine is still cloudy, scanty, of dark-brown 
color, and strong urinous {not ammoniacal) odor. 

Berberis. — Useful in the pains of chronic pyelitis. Sup- 
puration on the left side, very severe pain from left kidney 
down ureter to hip. Berberis vulgaris, first decimal dilution. 
Berberis is a remedy which is especially suited to disorders of 
the lumbar region. 

Special Therapeutic Measures. — In this disease, as in all 
others where pus formation occurs, administer protonuclein, 
one tablet every two hours, to repair the waste. 

Applications of antiphlogistine to the renal region should 
not be forgotten. 

In recent cases of moderate intensity Buchu, Arbutin and 
Gallic acid will sometimes reduce the amount of pus. 

In older cases, where there is much pus, Boracic acid in 
two to ten grain doses, largely diluted with water, often acts 
efficiently. 

In cases which have been aggravated by sexual excesses 
Damiana is said to be useful. 

Wet cups followed by warm poultices and leeching are 
advised by some writers when there is severe pain. 

Ox-gall with Nux and Pancreatin may be needed when 
there are digestive disturbances. 

In chronic cases change of air, especially from the interior 
to the sea, is recommended. 

For the gouty patient the imported Vichy water and the 
various alkalies are useful ; for the oxaluric patient Contrexe- 
ville water, and either Nitro-muriatic acid or Lysidin. (See 
Ox ANURIA.) 

Surgical Treatment. — Since pyelitis is sometimes due to 



346 DISEASES OF THE RENAL PELVIS. 

obstinate urethral stricture, the latter must be relieved, so 
that the urine may flow freely. 

In cases of calculous pyelitis it is necessary to remove the 
stone by operative measures. Tumors in operable cases 
should also receive attention. 

To prevent ascending pyelitis when an operation is per- 
formed on the lower genito-urinary organs careful aseptic 
measures, extreme gentleness, free bladders, drainage and in- 
ternal use of Salol or Urotropin are advised. 

In tubercular cases, if acute and primary, nephrectomy 
must be performed. 

Acute ascending pyelitis sometimes requires nephrectomy. 

According to Carleton, in chronic pyelitis due to obstruction 
to the free flow of urine, drainage of the bladder by perineal 
section is frequently of great benefit ; otherwise surgical relief 
will be required only in tubercular or lithaemic cases. 

Kelly treats pyelitis in women by ureteral douching of the 
pelvis of the kidneys with Boric acid, Silver nitrate, or Mer- 
curic chlorid solution. Adams has used the same treatment 
successfully in tubercular pyelitis in women. 

After introducing the ureteral catheter suction is used by 
means of a syringe to draw down thick pus, small stones or 
other obstructive material, following which the douche is 
made. 

TUBERCULOSIS OF THE PELVIS. 

This, as already described, may be miliary or caseous, the 
latter more common and always secondary, the former rare 
and apparently hsematogenous. 

The mucous membrane in chronic caseous tuberculosis is 
infiltrated and thickened ; caseation takes place, leading to 
ulceration. 

The ureter is involved first, either above or below, its wall 
thickened, its lumen reduced and sometimes obliterated ; or 
the disease may take the form of an ulcer. 



RENAL CALCULUS. 347 



TUMORS OF THE PELVIS AND URETER. 

Villous papilloma is comparatively frequent ; rarely, malig- 
nant papillomatous neoplasms occur. 

Carcinoma of the pelvis may be associated with calculi. 

Lymphosarcoma occurs in the pelvis. 

A tumor resembling adenoma has been found in the ureter, 
perhaps springing from rests of the Wolffian duct. 

Rarely, primary sarcoma has been found in the ureter. 

CYSTS OF THE PELVIS AND URETER. 

Multiple small cysts have been found in the pelvis, calices, 
bladder, ureter and urethra. Their origin is in doubt. 

PARASITES OF THE PELVIS. 

These are Distoma hcematobium, the Filaria sanguinis 
ho minis and the Eustrongylus gig as. The eggs of distoma 
occur in the urine in large numbers, appearing in small 
pointed bodies 0.12 mm. long and 0.04 mm. wide. They are 
oval and in the neighborhood of one pole there is a lateral 
process. 

Filaria causes hsematuria and chyluria. 

Strongylus gigas, the palisade worm, is rarely found ; when 
present it causes pyelitis and vesical tenesmus, with pyuria 
and hsematuria. 

The parasite shows six nipple-like papillae around the buc- 
cal orifice. 

These parasites are common in Egypt. 

RENAL CALCULUS. 

Synonyms. — Nephrolithiasis. Stone in the kidney. 
Definition. — The conditions associated with the formation 
of precipitates from the urine in the kidney or renal pelvis. 



348 DISEASES OF THE RENAL PELVIS. 

Occurrence. — In men rather than in women ; most fre- 
quently in children and elderly people. It occurs usually be- 
fore the age of fifteen and after fifty. It is more common in 
those who lead a sedentary life. Soldiers and sailors are free 
from it. Locality appears to favor it, as it is common in Eng- 
land and in Holland. Some persons cannot drink white wine 
without immediate formation of renal calculus. (Kichhorst.) 

Etiology. — The causes are as follows : 

i. Heredity. 

2. Locality. 

3. Sedentary and luxurious habits. 

4. Gout. 

5. Cystinuria. 

Renal calculus is frequently the result of the inheritance of 
various anomalies of metabolism as shown by lithsemia, oxa- 
luria, cystinuria, etc. 

Bacteria play a part in the formation since all conditions 
of urinary stasis are favorable to the formation of calculus. 

Cause of Formation. — Clots, shreds of tissue, and ova of 
parasites may serve as nuclei, but immediate cause of forma- 
tion is not always understood. The nucleus is usually organic. 

Varieties. — The most common are : 

1. Uric acid and urates. 

2. Calcium oxalate. 

3. Phosphates. 

Rarer are calcium carbonate, cystin, xanthin, and indigo. 

Size, Number and Form. — Calculi occur in one or both 
kidneys, are single or many, and vary in size from that of a 
grape-stone to that of a goose egg. They may be round or 
smooth, granulated or spinous, or irregularly branching, like 
antlers with protuberant knobs projecting into dilated calices. 
A Y-shaped stone blocking the ureter occurs. 

Properties of Calculi. — Calculi are found in acid urine, 
except phosphatic stones, which occur in alkaline. Uric acid 
are yellow, red or brown, lamellated when broken. Calcium 
oxalate (oxalate of lime) are dark-brown and dense. 



RENAL CALCULUS. 349 

Phosphatic calculi are gray, somewhat porous, aud easily 
broken. 

Cystin calculus is of a waxy character. 

Xanthin forms a hard brown stone. 

Indigo a dense blue mass. 

The urate and oxalate are most common. When there is 
ammoniacal decomposition of urine in the pelvis, the phos- 
phatic calculi may be deposited in which case the urine will 
contain a large amount of crystals of triple phosphate, which 
at first are unaccompanied by pus. 

A urate or oxalate stone may be coated with phosphatic 
deposit, in case the urine becomes ammoniacal in the pelvis. 

The so-called coral-stones are composed of uric acid and 
urates. They may form moulds of the renal pelvis. 

Fibrinous concretions sometimes occur, the result of antece- 
dent haemorrhage, and are of tough, flexible and extensile 
structure ; inflammable, burning with the odor of burnt 
feathers. 

Renal calculus, if in a calyx of the kidney, may have the 
shape of a pastel. Hundreds of them are sometimes found in 
the renal pelvis. 

Nephro-lithiasis may show itself by the passage of either 
sand, gravel or calculus. The term sand is applied to fine 
pulverulent material, gravel to particles of coarse grain and 
those which are the size of a pea. 

Diagnosis. — If a patient states that he has at one time 
passed gravel or sand in his urine, and if there is considerable 
sediment in his urine, dull pain, frequently retraction of the 
testicle, the dull pain is increased by deep palpation or by 
jolting, while seated in a vehicle, over rough roads, car tracks, 
etc. — especially if he has passed blood in his urine after such 
a trip — then the presence of stone is almost certain. 

Confirmatory of the above is a history of renal colic. (See 
Clinical Features.) 

Diagnosis by Catheterization of the Ureters. — Catheteriza- 



350 



DISEASES OF THE RENAL PELVIS. 



tion of the ureters with a wax-tipped catheter is the most 
direct means, says Kelly {Journal of Obstetrics, October, 
1 901), of ascertaining the presence of calculus in the urinary 
tract. The success of the method depends upon care and 
skill on the part of the examiner, together with attention to 
detail in preparing the instrument. The presence of the 
scratch-marks is the most important feature in diagnosis of 



A 



«PV\ 




%* 



i 




Fig. 23.— Calculous pyelitis. — (Rayer.) 



calculus by this means, but the method affords valuable con- 
firmatory evidence in other ways. In ureteral calculus the 
method by dilating the ureter and thus inducing the escape 
of the stone through the natural channel may obviate the 
necessity for operation. If all precautions have been taken^ 
the presence of scratch-marks is positive evidence of the exist- 
ence of calculus ; but the absence of scratch-marks cannot be 



RENAL CALCULUS. 351 

accepted as proof that no stone exists. The possible presence 
of a double ureter, with two openings into the bladder, should 
always be borne in mind. 

Clinical Features. — If the stone is smooth and embedded 
in the renal parenchyma, no- symptoms or inconvenience. 
Usually, however, the symptoms are as follows : 

i. Lumbar Pain. — A dull, boring ache, either fixed or radi- 
ating toward the genitals or upper portion of the thigh of af- 
fected side. The pain may be referred to the sound kidney. 

2. Irritability of the bladder. 

3. The posture and gait of the patient are affected. He 
walks with the body bent forward, with the shoulders de- 
pressed toward the affected side, with the vertebral column 
convex toward the healthy side, avoiding rotation and flexor 
movement of the vertebrae. In walking he is as stiff as a 
stick and places his feet with care gently on the floor 
especially the foot on the diseased side. (Kichhorst.) 

4. There may be reflex nausea and vomiting for weeks or 
months early in the case. 

5. Chills and fever in case pyelitis is caused. 

6. Renal colic. — Due to passage of the stone through or in- 
to the ureter, with symptoms as follows : pain beginning in- 
stantaneously, even when the patient is asleep ; more com- 
monly after exertion. The pain is cutting, stabbing, sharply 
defined along the course of the ureter, either toward the 
genitals or into the thigh. 

It may be most severe in the back or radiate upwards into 
the epigastrium. The pain may cease as suddenly as it came, 
if the stone slip back into the renal pelvis or pass into the 
bladder. Recurrence of paroxysm may take place, if stone 
again endeavors to pass from pelvis into or through the ureter. 

After the attack there is a period of prostration, and aching 
pain may persist in the region of the affected kidney for a 
considerable time after the stone has passed. 

Conditions Associated with Renal Colic. — Chilliness, chills, 



352 DISEASES OF THE RENAL PELVIS. 

faintness, nausea, vomiting; increased frequency of micturi- 
tion, and haematuria. The latter may be present several days 
after passage of trie stone. The quantity of urine is generally- 
less than normal, but, after the attack, polyuria is common. 
In rare cases there may be total suppression of urine, even 
though the stone is impacted in but one ureter. 

Death may result from anuria, whether due to shock of the 
intense pain or not is not known. Total anuria may persist 
from three to eleven days. 

Impaction of the stone in the ureter may lead to ulceration, 
perforation, abscess and peritonitis. 

Position of the Patient During the Attack. — Usually on 
the affected side, with up-drawn knees. Testicle of affected 
side is frequently retracted, or even swollen, if pain extends 
to the scrotum. 

Length of Time of Attack. — The spasm may last for an hour 
or more, or recurrent paroxysms may continue for many hours, 
with sudden relief, if stone enters the bladder. 

The Urine. — i. Persistent presence of blood-corpuscles in 
the sediment is a feature. At times, especially after exertion, 
blood visible to the naked eye. 

2. Features of pyelitis; pus in small quantity in acid urine; 
or chronic catarrh of the urinary passages. 

3. Passage of gravel. 

4. The writer with the aid of the centrifuge nearly always 
finds casts, hyaline or finely granular or yellow granular. 
They are probably dependent on the hyperaemia incited with- 
in the pelvis of the kidney. 

5. It is said that in some cases of unilateral renal calculus 
the urine is normal, and that in other cases evidences of renal 
disease, not calculous, appear. 

During renal colic there may be strangury, and it frequently 
happens that suppression and even uraemia supervene, although 
the opposite kidney be perfectly normal. Some patients on 
the other hand during an attack void large quantities of clear 
urine. 



RENAL CALCULUS. 353 



ANALYSES OF THE URINE IN RENAL CALCULUS. 

In the case of a man from whose kidney Dr. Charles Adams 
removed a large stone, the following analyses of the nrine 
were made by the writer prior to the operation : 

First Analysis. Second Analysis. 

Volume per 24 hours, 725 c.c. (24 fl. oz. ) 1400 c.c. (47 fl. oz.) 

Ratio of day urine to night, ... 0.7 to 1. 0.4 to 1. 

Urea total, 18.5 gms. (285 grs.) iS gms. (280 grs.) 

Phosphoric acid, ....... . 1.3 gms. (20 grs.) 1.47 gms. (22 grs.) 

Uric acid, 0.7 gms. (n grs.) 

Urea to phos. acid 13 to 1. 14 to 1. 

Urea to uric acid, 26 to 1. 

Specific gravity, ..... . . 1.019. 1012. 

Total solids, 30 gms. 34 gms. 

Albumin, (Esbach) 0.05 %. 0.0016 %. 

Pus sediment, Abundant. Abundant. 

Crystals None. None. 

Casts, A few granular. None. 

Epithelia, Renal. Renal and bladder. 

These analyses show the following : 

1. Stone in the kidney is not necessarily accompanied by 
excess of solids in the urine. 

2. Total urea and total phosphoric acid may be deficient in 
the urine of a patient having stone in the kidney. 

3. With deficiency as above of urea and phosphoric acid, 
uric acid may, however, be in considerable relative excess. 

4. Crystals may be at times entirely absent from the urine. 

5. Casts may be found at times. 

In several other cases confirmed by operation the writer has 
found casts. 

Situation of the Calculus. — If the calculus be in the sub- 
stance of the kidney, and there is no pyelitis, pain slight, or 
severe for a time and then disappearing for years. Sometimes 
constant dull pain in the loin. No general disturbance. 

If the calculus be free and moving iii some large cavity of 
the kidney or in renal pelvis, the pain is felt not only in the 
23 



354 DISEASES OF THE RENAL PELVIS. 

loin, but along the course of the ureter, and even as far as to 
testicle, inner aspect of thigh, or lower part of leg, even in the 
heel. Pain much worse on motion. 

If the calm his be dislodged from the infundibula or from 
fixed position in renal pelvis, pain, then severe and paroxys- 
mal nausea, faintness, vomiting. 




Fig. 24.— Radiograph of oxalate stone in substance of the kidney.— (From Fenwick.) 

If the calculus be in the ureter, then renal colic, agonizing 
pain, nausea, faintness, writhings and contortions, even con- 
vulsions. After some hours, pain subsides suddenly. There 
may be sudden suppression of urine on one side ; urine re- 
duced suddenly to half the normal quantity. 

If the calculus be impacted in the ureter, pain sets in sud- 
denly and is only gradually relieved ; does not cease suddenly, 
but there are paroxysms of pain, until finally the ureter be- 
comes habituated to the presence of the stone. 



RENAL CALCULUS. 355 

If the calculus be impacted in the ureter close to vesical 
exit, site of pain, after having for some time shifted in a direc- 
tion generally downward, suddenly becomes fixed ; there is 
evidence of suppression of urine on one side. 

If the calculus has become merely displaced from renal orifice 
of ureter, but is not yet in bladder, another paroxysm of pain 
may take place at any time. 

If calculus has passed into bladder, patient may possibly be 
aware of it. The renal colic ceases and after a time signs of 
the presence of the stone show themselves as follows : Hema- 
turia after strong bodily exertion, disappearing after a long 
rest ; day urine contains more blood than night ; the urine 
begins to show the features of cystitis. (See Cystitis.) 
Sounding for stone will sometimes reveal its presence. 

Both kidneys affected or one only '? If the stone is primarily 
phosphatic the disorder is limited to one kidney. 

If the stone is uric acid or oxalate, both kidneys may be 
affected. 

If during renal colic, while one ureter is blocked, the urine 
voided be perfectly normal, then the one kidney is healthy. 

In doubtful cases try compression of ureters or catheteriza- 
tion. 

It must be remembered that absence of the symptoms men- 
tioned above does not necessarily signify absence of calculus. 
In some cases the diagnosis cannot be made with certainty. 
The urine is often normal in all respects and gives no sign of 
the presence or character of the calculus. Renal colic may 
be the first marked symptom. Moreover, the symptoms of 
calculus, viz., lumbar pain, extending at times to the groin 
and testicle, paroxysmal, aggravated by movements, accom- 
panied or followed by hematuria, pyuria, and frequent mic- 
turition, may all be present, and yet there be neither stone in 
the kidney nor disease of the bladder. (See Tuberculosis 
of Kidney.) 

The writer's paper in Dr. Aldrich's Minneapolis Journal 
was as follows : 



356 DISEASES OF THE RENAL PELVIS. 



TYPICAL CASES. 

Typical cases of renal calculus may usually be recognized 
without much difficulty by paying attention to the history 
and clinical features of the case. The patient is either a child 
-or more commonly a middle-aged male adult, with previous 
history either of good general health or of the uric acid dia- 
thesis, who lives or has lived in a limestone district, especially 
where the hard water of artesian wells is used. His habits 
are usually, though not invariably, sedentary or luxurious, 
and he is likely to be a hearty meat eater, or a beer or wine 
drinker. In most cases he begins his illness by feeling a dull 
pain in the loin, which is aggravated by riding, especially 
over a rough road. Sometimes there is marked sensitiveness 
to pressure over the region of the affected kidney, and the 
patient flinches from the touch of the physician's thumb or 
finger. In some cases there is no sensitiveness over either 
kidney, even on deep pressure. In one such case seen by the 
writer the patient insisted that the pain was affected by the 
weather, being worse in damp weather. 

Sooner or later renal colic takes place, quite often after 
violent sudden exertion, jolt or fall. In one case observed by 
the writer it came on when the patient tried to lift a trunk. 
Sometimes, however, renal colic appears after but slight exer- 
tion, and occasionally it may occur even when the patient is 
quiet in bed. 

Renal colic begins suddenly ; the pain is cutting, stabbing, 
sharply defined, follows the course of the ureter towards the 
genitals, or into the thigh. The testicle on the affected side 
is frequently retracted ; there may be chills or chilliness, 
elevation of temperature, faintness, nausea and vomiting. 
The pains may be in some cases more severe in the back or 
radiate upward into the epigastrium. After an hour or so 
the severe pain may cease as suddenly as it came on, after 



RENAL CALCULUS. 357 

which there is more or less prostration, and an aching pain in 
the region of the affected kidney, persisting for a considerable 
time. 

Whether the patient has renal colic or not, the condition of 
the urine is important. Persistent presence of blood corpus- 
cles, or of blood, visible to the naked eye, is a common feat- 
ure, while at the same time the symptoms and history of other 
maladies, as renal congestion, genito-urinary tuberculosis, 
bladder, prostatic or urethral lesions, by which the presence 
of blood can be accounted for, are absent. Blood in the urine, 
more abundant after exercise, together with pain in the loin, 
should always arouse the suspicion that calculus is present in 
the kidney. Especially is this suspicion warranted, if the 
haemorrhage does not occur immediately after the exercise 
or exertion in question, but follows after some hours, or even 
on the next day ; for example, a man rides around his farm 
on Monday, and on Tuesday has a urinary haemorrhage. 

Next of importance, though not of frequent occurrence, is 
the presence of sharp, spiny, reddish crystals of uric acid in 
the urine, easily seen by the microscope with a low power, 
say, 150 diameters. These signify hyper-acid urine and de- 
posit of crystals in the uriniferous tubules, and also in the 
calices and pelvis. 

Sharp-pointed crystals of uric acid without blood may be 
found in the urine in cases of rheumatism ; sometimes together 
with blood in renal tumors. As a rule, however, blood and 
sharp uric acid crystals signify calculous pyelitis. Quite com- 
monly any crystals of uric acid may have sharply defined 
edges, but unless they taper to a sharp point they are not to 
be regarded as significant. Crystals of urate of ammonium in 
stale or decomposed urine have small spiny projections, but 
the latter can be seen plainly only with a high power, say, 500 
diameters. When the ureters can be catheterized, excess of 
any crystals found in the urine of one side over that from the 
other is an important aid in diagnosis. 



358 DISEASES OF THE RENAL PELVIS. 

In cases of renal calculus, when blood is found in the urine, 
it is almost always more abundant in the day urine than in 
the night, whereas in tumor or in tuberculosis, haemorrhages 
at night are not unusual. 

Next in importance is the occurrence of pus in the urine, 
with or without blood or crystals. In cases in which there is 
much sensitiveness to pressure over the affected kidney, to- 
gether with pus in acid urine, it should arouse the suspicion 
that calculus is present, even if blood and crystals can not be 
found in one or two examinations. If the urine is watched 
carefully and examined repeatedly, blood corpuscles will in 
all probability eventually be found by the microscope, if renal 
calculus is present. 

Again, it seldom happens in cases of renal calculus that 
tube-casts are absent from the urine. They are usually of the 
hyaline variety, with renal epithelium scattered about in them, 
the latter being stained yellow by the coloring matter of the 
blood ; sometimes we find, also, yellow granular casts. As a 
rule, casts, when present, are not abundant, five or ten in all 
in the sediment of half a fluidounce of urine. When much 
pus is present in the field, tube-casts may escape notice. 

Lastly, it is not unusual to find a low ratio of urea to uric 
acid ; less than forty parts of urea to one of uric acid, when 
the patient has not yet been put on a diet. 

The diagnosis may be confirmed by the X-ray, especially in 
thin patients and where the calculus is large, but a stone in a 
fat person may not be detected by this means. 

ATYPICAL CASES. 

Cases occur in which the stone is too large to pass 
through the ureter into the bladder, so that a typical renal 
colic, beginning suddenly and ending suddenly, is not ob- 
served. In such cases there are recurrent attacks of back- 
ache, chill, fever and high colored urine. If the calculus be 
dislodged from the infundibula or from fixed position in the 



DIFFERENTIAL DIAGNOSIS IN RENAL CALCULUS. 359 

renal pelvis, then there may be observed the usual symptoms 
of renal colic, viz., severe paroxysmal pain, nausea, vomiting, 
faintness, etc., lasting until, for any reason, the stone slips 
back out of contact with the ureter into the pelvis of the 
kidney again, which it may not do for hours. The pain, in 
such cases, recurs from time to time, according to circum- 
stances. If the calculus becomes impacted in the ureter, the 
pain sets in suddenly and is only gradually relieved, the 
paroxysms recurring until the ureter becomes habituated to 
the presence of the stone. Cases occur in which the stone 
becomes impacted in the ureter, close to the vesical orifice, in 
which case the site of the pain, after having for some time 
shifted in a direction generally downward, suddenly becomes 
fixed and the quantity of urine may be diminished materially, 
owing to suppression on the affected side. 

Cases also occur like the one mentioned at the beginning 
of the article, in which backache and obscure nervous symp- 
toms are the only clinical features, the urine being normal in 
all respects. The first marked symptom in this class of cases 
may be renal colic. 

On the other hand, renal colic may be experienced and 
stone be absent altogether, the pain being due to the passage 
of tuberculous material, or hydatid sacs, or simulated by kink- 
ing of the ureter or spasm of the ureter. 

DIFFERENTIAL DIAGNOSIS. 

The differential diagnosis of renal calculus from other 
maladies is of the utmost importance, because of the bearing 
on treatment. Cases frequently occur, to the surprise of all 
concerned, in which operation for calculus fails to find any 
stone at all. 

The diseases which may simulate renal calculus are as 
follows : 

i. Most commonly, renal tuberculosis (primary). 

2. Movable kidney with kinking of the ureter (Dietl's 
crises). 



360 DISEASES OF THE RENAL PELVIS. 

3. Chronic interstitial nephritis with adhesions. 

4. Inflammation and dilatation of the renal pelvis from 
causes other than stone. 

5. Reflex spasm of the ureters or of the right ureter alone. 

6. Nephritis with backache and conditions of tension. 

7. Paranephric abscess. 

8. Various colics; appendicular, hepatic, gastric, intestinal, 
and that of lead poisoning. 

9. Malaria. 

10. Stone in the bladder. 

11. Dysmenorrhea. 

12. Spinal caries. 

13. Locomotor-ataxia. 

14. Renal hydatids. 

15. Malignant growths. 

In primary renal tuberculosis we find the patient under 
forty years of age; commonly a puny, pale, lightweight, 
anaemic male, between twenty and forty, with cold hands and 
clubbed ringer nails. The ringer in the rectum may discover 
nodules in the prostate and seminal vesicles. He has in- 
creased frequency of urination, both at night and by day, 
while the patient with renal calculus has frequency chiefly 
during attacks of renal colic. The tuberculous patient may 
pass blood freely during the night, while the patient with 
calculus seldom voids blood at all during the night, or if he 
does, it is in small quantity, compared with the day. 

The tuberculous patient is likely to have more or less 
pyrexia and symptoms referable to the bladder, which are not 
characteristic of renal calculus. Discovery of the bacillus of 
tuberculosis is an aid in diagnosis, as is also the presence of 
caseous masses in the urine. The patient with renal tuber- 
culosis never feels well, but the patient with renal calculus 
often feels entirely well between attacks. 

Moveable kidney with kinking of the ureter may give rise 
to attacks simulating renal colic. The attacks (Dietl's crises) 



DIFFERENTIAL DIAGNOSIS IN RENAL CALCULUS. 361 

of abdominal pain are severe, with chills, fever, nausea, vomit- 
ing and prostration. The urine during the attack is scanty, 
contains an abundance of urates and oxalate crystals, and 
both blood and albumin may be present. During the attack 
a swelling may be perceived, due to hydronephrosis, which 
subsequently disappears when the attack is over, and a copious 
flow of clear urine takes place. If, as is not rarely the case, 
the movable kidney is nephritic, albumin and casts will be 
found in the clear urine voided after the attack. Rarely, 
movable kidney without kinking of the ureter, is accompanied 
by hematuria, probably from congestion, as suggested by A, 
T. Cabot. 

In movable kidney the patient is usually a thin person, 
especially a thin woman, who has borne children in rapid suc- 
cession and who has a history of a complexus of symptoms, 
mental, neurasthenic, gastro-intestinal, hepatic, uterine and 
ovarian. After the crisis of pain is over, it is often not dif- 
ficult to perceive, by palpation, a movable tumor in the loin, 
manipulation of which may cause peculiar sinking, fainting 
sensations. Cases may now and then occur in stout persons, 
and the differential diagnosis from stone dislodged, but not 
passed, is then difficult. In such cases persistent examination 
of the urine must be made for the more or less continuous 
presence of blood corpuscles and casts of the hyaline or yellow 
granular form, as significant rather of calculus than of neph- 
roptosis. But if in a stout person, a movable kidney hap- 
pens to be also nephritic, it may be impossible to differentiate 
definitely without long observation of the case, unless the 
urinary features of renal calculus above described become 
marked. In cases where, between attacks of pain, the urine 
is normal, the chances are in favor of movable kidney rather 
than calculus. 

In chronic interstitial nephritis, with density of structure of 
the kidney, it sometimes happens that there are adhesions to 
the surrounding parts and retractions under the ribs, evoking 



362 DISEASES OF THE RENAL PELVIS. 

attacks of fixed renal pain, accompanied by frequency and 
difficulty of micturition. In such cases we have the cardio- 
vascular symptoms of contracting kidney, the absence of blood 
and crystals from the urine, except in hsemorrhagic cases, and 
the characteristic urine of contracted kidney, namely, of low 
specific gravity, poor in solids and especially in uric acid. In 
these cases it is said that nephropexy relieves the attacks of 
pain. 

An inflamed and dilated renal pelvis, without presence of 
stone, may cause attacks of pain simulating renal colic. 
Cases have occurred in which operations for stone have been 
performed, and although no stone was found, recovery has 
taken place afterwards. In stout patients differentiation from 
calculus is difficult, but in thin persons the X-ray is of value 
in the diagnosis. The history of the case becomes important 
in making the diagnosis; anything which points to the 
passage of an irritant, bacterial or toxic, though the kidneys, 
or especially infection from operations on the lower urinary 
tract, being in favor of non-calculous pyelitis. The general 
condition of the patient in most cases of renal calculus is good, 
and the history often that of freedom from previous illness. 

Spasm of the ureter, occurring in women, may be mistaken 
for renal colic. This is usually a sequence of urethritis. 
The patients describe the spasms as occurring most often dur- 
ing the night ; they awake with a pressing desire to urinate ; 
the emptying of the bladder is accompanied by more or less 
pain and spasm, and followed by a cramp-like pain, ascending 
along the course of the ureter to the kidney, and also radiat- 
ing to the lower extremity. The diagnosis of urethral lesion 
is of aid in differentiating this spasm from renal colic ; or else 
the history of some previous disease in the lower urinary tract 
shows the reflex nature of the spasm. Absence of stone 
shown by the X-ray in thin persons, or of blood, pus, or ex- 
cess of crystals, shown by ureteral catheterization, will help 
to exclude renal calculus. 



DIFFERENTIAL DIAGNOSIS IN RENAL CALCULUS. 363 

In either sex, spasm of the right ureter alone may occur 
and be reflex and sympathetic, due to disease in the gall- 
bladder, appendix or colon. Examination of the urine, how- 
ever, shows no evidences of renal calculus in such cases, and 
the latter may be excluded, as above, by the X-ray or by 
ureteral catheterization. 

The backache occurring in nephritis is usually readily re- 
cognized as such by the presence of a comparatively large a- 
mount of albumin in the urine, and of numerous and various 
casts. If, in addition, pallor, weakness, dyspnoea and oedema 
are found, the diagnosis of nephritis becomes more certain. 

Conditions of tension of the capsule of the kidney not in- 
frequently simulate stone, as in cases of acute hypersemia and 
in hypertrophy of the organ. If operation for stone is per- 
formed and the search for the latter made by splitting the 
kidney along the convex border, the tension is relieved and 
the symptoms cease after operation. 

lit paranephric abscess the pain may be severe, and the 
renal congestion such that blood-corpuscles are found in the 
scanty, high-colored urine. The course of the disease is such, 
however, as to enable us usually to differentiate without diffi- 
culty. The history is also of service, as this disorder is the 
result of extension of an inflammatory process from elsewhere, 
as from appendicitis, pelvic cellulitis, and various suppurative 
lesions. It also occurs from a wound or surgical operation, 
and as a sequence of infectious diseases. 

In paranephric abscess we eventually find a painful tumor 
in the region of the kidneys, with chills, fever, etc. In renal 
calculus we have usually a history of good previous health, or 
at least of an absence of suppurative or infectious disease, and 
tumor is absent except in cases where impaction leads to hy- 
dronephrosis or pyonephrosis, neither of them so sensitive to 
pressure nor so extremely painful as the paranephric abscess. 

Appendicitis is a disease which, when not typical, must be 
differentiated from renal calculus. Ordinarily, renal colic is 



364 DISEASES OF THE RENAL PELVIS. 

distinguished by the absence of tumor, fever and spot of ten- 
derness, but atypical cases of appendicitis may be mistaken 
for renal colic, especially when there is no tumor, no marked 
temperature, and when the pain is in the right hypochondriac 
region. If there is localized extreme tenderness in the right 
lower abdomen, appendicitis is the cause, but when the point 
of greatest pain is in the right hypochondriac region, care 
must be -observed to determine whether or not it is " the spot 
of tenderness " of appendicitis in an unusual location, or 
whether it is simply the locality where the pain is the worst. 
The general tendency in appendicitis for the pain to settle 
rapidly into the appendicular region js a help in differentiat- 
ing. Moreover, the character of the pain in the two diseases 
is likely to be different. In renal colic it is the writer's ex- 
perience to find in the intervals between the severest attacks 
a tendency on part of the patient to brace his feet, if he can, 
against something ; whereas, in appendicitis the general ten- 
dency is to draw up the leg on the affected side. 

It must not be forgotten that the urine in appendicitis is 
scanty, and that micturition may be frequent, as in renal 
colic. Moreover, retention of urine later in the case is 
noticed in appendicitis, which may be mistaken for the sup- 
pression of urine, which is sometimes noticed in renal cal- 
culus. If we find in the urine blood-corpuscles, casts and 
crystals, especially sharp uric acid crystals, while at the same 
time it can be decided that a spot of extreme tenderness is ab- 
sent, even though we can find the locality of greatest pain, 
the chances favor renal calculus, especially in the absence of 
tumor and temperature, and especially if the pain does not 
settle into the appendical region. L/eucocytosis being absent 
is also in favor of renal calculus. It must not be forgotten, 
however, that a patient with slight calculous pyelitis may be 
seized with acute atypical appendicitis, in which case the de- 
termination of a spot of real tenderness and the presence of 
leucocytosis are of importance. Some clinicians dwell on the 



DIFFERENTIAL DIAGNOSIS IN RENAL CALCULUS. 365 

fact that in renal calculus the pain may radiate into the groin 
and testicle, but this may also be true of the pain of appendi- 
citis, at least after it has settled into the appendicular region. 

Hepatic colic may be mistaken for renal colic before the oc- 
currence of jaundice, and when there is no bile in the urine. 
Cases are commoner in women than in men. The pain of 
gall-stone colic is usually preceded by a feeling of intense full- 
ness in the region of the liver, coming on several hours after 
meals. The pain is located over the liver, over the gall- 
bladder, toward the umbilicus, toward the right shoulder, 
sometimes toward the epigastrium. Tenderness on pressure 
is present and remains after the pain ceases. Jaundice, to- 
gether with biliary matter in the stools and urine, favors the 
diagnosis of hepatic colic. An inflamed and distended gall- 
bladder presents pain, tenderness, tumor and fever. The 
tumor is pear-shaped, movable, and is rather above than be- 
low the level of the navel, and is more likely to be confounded 
with renal tumors than with renal calculus. 

The tendency of renal colic to make the testicle tender and 
retracted is of service in differentiating renal calculus from 
both hepatic and intestinal colic, as is also the condition of 
the urine. 

Intestinal colic is not so sharply denned as renal colic, and 
lacks the retraction of the testicles and the urinary features of 
renal calculus. Both intestinal and gastric colic tend to im- 
prove rapidly. 

The colic of lead poisoning m&y be inferred from the history, 
the presence of a blue line around the gums, paralysis of the 
extensors, and obstinate constipation. The urinary features 
are either lacking or are those of contracted kidney. 

Singularly enough, renal calculus has been mistaken for 
malaria. In some cases, when the stone is too large to be 
voided by the ureter, recurrent attacks of non-suppurative py- 
elitis may occur, and the backache, chill, fever and high-col- 
ored urine closely simulate malarial attacks. Presence of 



366 DISEASES OF THE RENAL PELVIS. 

blood-corpuscles, microscopically, and of sharp, spiny crystals 
of uric acid, together with the absence of the plasmodium 
from the blood, tends to show presence of renal calculus, es- 
pecially when the climate and the history do not support the 
diagnosis of malaria. 

Stone in the bladder is sometimes mistaken for stone in the 
kidney. More commonly stone in the kidney is mistaken for 
stone in the bladder, especially when phosphatic calculus is 
present. But when the renal stone is phosphatic, in such 
cases as have occurred in the writer's experience, the urine 
contains a large quantity of triple phosphate crystals with 
neither sticky pus and blood, nor the micro-organisms that 
we find in vesical calculus. If, at the same time, the classical 
symptoms of bladder-stone are absent, namely, frequent and 
painful urination, together with stoppage of the stream, with 
a twinge of pain shooting along the course of the urethra to 
the meatus, the presumption is in favor of the presence of 
renal rather than vesical calculus. Moreover, it will be re- 
membered that the pain and frequency in cases of vesical 
stone are worse on motion and aggravated, therefore, by walk- 
ing, not so much by riding in a carriage or other vehicle. 
The X-ray should, in many cases, be of service in detecting 
stone in the bladder, to say nothing of what is found by use 
of the sound ; the history of residual urine, or the prior occur- 
rence of renal colic, will aid us in distinguishing vesical stone. 
In cases of stone in the bladder, the urine may be very 
strongly ammoniacal, and the pain on urinating extreme, 
which is not common in cases of renal calculus. 

Dysrnenorrhcea should not be confounded with renal cal- 
culus, if attention is paid to the comparative regularity in 
the periodicity, and to the absence, between attacks, of blood- 
corpnscles from the urine. Moreover, the connection of the 
pain with the menstrual flow should be evident. 

Spina/ caries is sometimes distinguished with great difficulty 
from renal calculus. An abscess in connection with spinal 



DIFFERENTIAL DIAGNOSIS IN RENAL CALCULUS. 367 

caries may open into the pelvis of the kidney, and pns be 
found in the urine. Absence of abnormal constituents of the 
urine prior to the sudden appearance of a considerable quan- 
tity of pus will aid in differentiating. 

The pain in renal crises of locomotor ataxia should be easily 
differentiated from that of renal calculus by the associated 
presence of Argyll-Robertson pupil, the loss of knee-jerk and 
the disturbances of co-ordination. It must not be forgotten 
that cystitis is frequently observed in locomotor ataxia, hence 
the presence of pus and triple phosphate crystals should not 
lead us to infer that renal calculus is necessarily present. 

Renal hydatids may give rise to renal colic from passage of 
the hydatid sacs through the ureters. In this case there is 
further trouble in expelling the vesicles through the urethra. 
Retention of urine takes place, with excessively frequent de- 
sire to pass water, and there is severe pain extending to the 
end of the penis. When once the vesicles are expelled, which 
may require considerable force, relief follows. The diagnosis 
of hydatids presents no difficulty when there is a tumor in the 
loin and when the vesicles are found in the urine. When, 
however, vesicles are absent from the urine, the tumor may be 
mistaken for hydronephrosis and in turn it may be assumed 
that the latter is due to impacted calculus. In such a case, 
unless the history is of service, as, for example, that of use of 
uncooked meats and salads in places where dogs are numer- 
ous and live in close association with their masters, the diag- 
nosis is practically impossible. 

Malignant growths have been mistaken for renal calculus. 
Owen describes at length a case in which the symptoms de- 
scribed by the patient and his attending physician were signi- 
ficant of renal calculus — gravel seventeen years before, frequent 
micturition, pain in thigh and testis, hematuria, and rigidity 
of the muscles over the left kidney. The kidney was ex- 
plored and found to be perfectly healthy. The patient died 
three days after the operation, apparently of exhaustion. The 



368 DISEASES OF THE RENAL PELVIS. 

autopsy showed an epithelioma of the descending colon with 
metastatic nodules in the liver. Ureteral catheterization and 
the Roentgen ray might have been of service in this case. 
(Adams.) 

Whether the stone is in the right kidney or the left is a 
matter which can not be settled in all cases without the use 
of the X-ray. 

Owen cites a case in which the patient had experienced dull 
pains in the back ten years previous to admission. About five 
years before he had a severe attack of renal colic on the left 
side and had passed blood and small calculi on several occa- 
sions. For the two years previous to admission, however, the 
pain had been on the right side, and the patient was firm in 
the belief that the small calculi passed from time to time had 
come from the right kidney. An exploratory operation on 
the right side showed the right kidney to be larger than 
normal, but otherwise healthy. About a month later the left 
kidney was opened and a calculus found. (Adams.) 

Associated Conditions. — Commonly, dilatation of renal 
pelvis, which is often extreme, and pyelitis ; abscess of the 
kidney or paranephritis may result from the pyelitis, the 
latter shown by increase in size of renal tumor and persistent 
elevation of temperature. Chronic interstitial nephritis may 
also result with mild uraemia, or amyloid disease with pro- 
longed cachexia. 

There may be renal-pelvic fistula, ureteritis and cystitis. 

Duration. — Cases may begin in childhood, last fifteen years 
or more, and recover under proper treatment. 

Cases have been known to last as long as thirty years. 

On the other hand a patient may after the age of fifty pass 
a stone and not be troubled again during life, especially if he 
obtain proper treatment. 

In chronic cases nausea and persistent headache point to 
uraemia, while splenic and hepatic enlargement suggest amy- 
loid kidney. 



TREATMENT OF RENAL CALCULUS. 369 

Prognosis. — Immediate, generally favorable. Successive 
attacks not necessarily fatal. 

Continuous presence of stone in the pelvis is a menace to 
health, on account of possibility of production of serious re- 
nal inflammations and degenerations. 

Anuria is a serious complication ; not always fatal, even if 
it continue twenty days. 

Repeated attacks of pain or the occurrence of pyelitis are a 
source of danger and call for surgical interference. 

After passage of the stone, if possible per urethram, recurr- 
ence does not necessarily take place. 

The prognosis is serious when pyelo-nephritis is present or 
contracting kidney. 

Treatment. — Preventive : If calculus is suspected, great 
care must be taken to avoid violent, and particularly sudden, 
exertions, jolts, falls, or the lifting of heavy objects. 

In case of uric acid calculus non-nitrogenous food, with 
avoidance of sweets, is essential. 

All circumstances which favor the deposit of the various 
urinary salts in the kidneys should be guarded against. The 
not infrequent habit of drinking beer and eating heartily of 
meat, after exercise and profuse perspiration, is to be con- 
demned, as it is conducive to hyperacidity of the urine on the 
following day, which in turn makes likely the deposit of uric 
acid crystals in the kidneys. Those who live in limestone 
districts should avoid, if possible, the hard water of artesian 
wells. It is now possible to purchase a complete apparatus 
for the distillation of water at a comparatively cheap price. 
Fifteen dollars will buy a still which will distill enough 
water for the use of a family of four people at a cost of about 
fifty cents a month. Those who can afford it should procure 
this apparatus. The writer has used distilled water as a bev- 
erage for several years, and finds it sufficiently palatable. In 
persons whose urine is habitually strongly acid and prone to 
deposits of urates or uric acid, regular ingestion of not less 
24 



370 DISEASES OF THE RENAL PELVIS. 

than three pints of distilled water daily should be observed, 
meat should be eaten moderately, sweets, fats, beer and cham- 
pagne avoided altogether. 

Those subject to intestinal indigestion and deposit of oxalate 
crystals should avoid apples, spinach, tomatoes, sorrel, ba- 
nanas and rhubarb, and take digestive tablets with meals at 
times when there are digestive difficulties. Hard water, tea 
and cocoa should be carefully avoided by them. In cases 
where the urine is alkaline and cloudy from phosphatic sedi- 
ments, five-grain doses of Urotropin may be taken occasionally 
to give the urine its normal reaction and prevent decomposi- 
tion of mucus. See also Phosphaturia. 

As a rule, open air life, with ingestion of plenty of soft 
water and use of a simple dietary, is a good prophylactic 
against stone. Sedentary or luxurious habits, rich foods and 
alcoholic drinks seem to be conducive to stone formation. 

The patient should avoid foods containing the nuclein 
bodies as the thymus, spleen, brains, lymphatic glands, liver 
and kidneys. 

Vegetables and fruits should be eaten, especially oranges, 
and alkaline waters drunk except in the case of phosphatic 
calculi. Cream should be avoided. 

Tepid baths (95 ° F.) taken twice daily are said to be useful. 

Massage once or twice a week and frequent rubbing with 
rough towel or flesh brush are helpful. Daily massage of the 
affected side should be practiced. Sexual excess should be 
avoided. 

Alkaline mineral waters are useful : Londonderry, Buffalo, 
Geneva, Waukesha, imported Vichy and Saratoga. It is pos- 
sible that artificial waters act even better, as, for example, 
those made by adding lithium carbonate to charged water, or 
sodium or potassium bicarbonate. A very efficient water of 
this class is the White Rock Lithia. 

R. H. Fitz recommends a benzoated water, as follows : 

Fifteen grains each of lithium benzoate and carbonate to- 



TREATMENT OF RENAL CALCULUS. 371 

gether with twenty grains of potassium bicarbonate, are dis- 
solved in a pint of carbonic acid water. Dose, two pints daily . 

Piperazin in doses of five grains, twice or thrice daily, in 
large quantities of water, is of value in dissolving uric-acid 
calculi. The dimethyl-tartrate (lycetol) is perhaps better 
than the pure piperazin, in doses from four to eight grains, 
so as to give in all not more that twenty-four grains per diem. 

L/ysidin is used as a uric solvent in doses of 10 minims of 
the 50 per cent, solution largely diluted with water, three 
times daily. 

The salts of lithium in seven and a half grains (0.5 gm.) 
doses are favorite solvents. Benzoic acid in the same dose 
may be given. Urotropin is also used. 

It is claimed by von Noorden and others that Calcium Car- 
bonate in doses of from ten to fifteen grains, three times daily 
prevents the formation of calculus. 

Other solvents are Magnesium Borocitrate (15 grains in 3 fl. 
oz. of water,) a tablespoonful every hour ; Uricedin seven and 
one -half grains (0.5 gm.) four times daily. (See Uric Solvents). 

Those subject to phosphatic calculi should avoid excess of 
vegetables and fruit and take the following mixture: dilute 
Hydrochloric acid and dilute Nitric acid, each thirty minims, 
distilled water, six fluidounces, syrup of red raspberry, one- 
half fluidounce, mix and take one tablespoonful (15 c.c.) 
every two hours. 

Uric Solvents. — Numerous preparations known as uric acid 
solvents are now to be had. Among them the following : 

Acetyl-methylene di-salicylic acid, known as Ur-a-sol; dose 
five to twenty grains. Acetyl-methylene di-salicylate of 
Theobromin, known as Diurazin, dose five to twenty grains, 
also a diuretic and said not to depress the heart ; dimethyl- 
piperazin, sidonal, uricedin, lycetol; tetra-ethyl-ammonium 
hydrate : dose, five to ten minims of a ten per cent, solution, 
three times daily, after meals, well diluted with water. 

The dissolving powers of any uric acid solvent is according 



372 DISEASES OF THE RENAL PELVIS. 

to Vicario measured by the solubility in water of the urate 
formed by the solvent in question in the body. 

Weiss has found in quinic acid a preparation which is 
capable of stopping the formation of uric acid in the system, 
and thus accomplishing something which is of the greatest 
importance to us in the treatment of gout. This quinic 
acid has been combined with piperazin, forming a most 
desirable, agreeable and easily dispensed product, known as 
Sidonal. 

The dose is five grammes (jj grains) a day given in aqueous 
solution, one-half in the forenoon and the other half in the 
evening. 

According to Vicario, urotropin and piperazin urates are 
eight times more soluble than lithium urate. L,ysidin urate 
is twenty times, and dimethylpiperazin urate is twenty- 
three times more soluble than lithium urate. 

The origin and prophylaxis of oxalate calculi have been 
studied by C. Klemperer, of Berlin, who declares that these 
stones are more frequent than is usually assumed. Their pro- 
duction is favored by foods rich in lime, as well as by sub- 
stances containing oxalic acid, as vegetables, and glycocol and 
kreatinin, which are derived from it, produce it. He recom- 
mends magnesium as a solvent, which is present in meat and 
in the leguminosae, while milk is not to be advised, as it is 
rich in lime and poor in magnesium. He, therefore, would 
have such patients take magnesium sulphate in doses of about 
two grammes a day. Senator thinks the stand of Dr. Klem- 
perer well taken, for it explains the oxaluria of young children 
who use milk so much. 

Symptomatic Treatment. — The principal remedies are Ar- 
gentum nitricum (dull aching pain across the back and 
extending to the bladder, dark acid urine containing uric 
acid). 

Berberis (in renal colic with sharp stitching pains and red 
sediment in the urine). 

Calcarea carb. (in high potencies for renal colic). 



TREATMENT OF RENAL CALCULUS. 373 

Cantharides (in children with, gravel, and also for the pains 
and congestion during passage of calculi). 

Coccus cacti (lancinating pains and red sand in the urine). 

Cannabis (urging to urinate with much straining). 

Dioscorea (pain shooting into the testicles and leg, with 
cold, clammy sweat over the body). 

Lycopodium (dull pain relieved by micturition ; renal colic, 
especially of the right side ; urine scanty, high colored ; red, 
sandy deposit composed of urates and uric acid ; urine some- 
times contains mucus and pus, causing a whitish sediment. 
Greasy pellicle on the surface of the urine ; itching in the 
urethra during and after micturition). 

Nitric acid (oxalate calculi). 

Nux vomica (pain extending from the renal region into the 
genital organs or leg, usually associated with intense and con- 
tinuous backache ; painful, ineffectual desire to urinate ; urine 
passed drop by drop, with burning, tearing pains at the neck 
of the bladder. Acts best on the right side. Reddish urine 
with brick-dust sediment ; burning and lacerating pain in the 
neck of the bladder during micturition. Use third decimal). 

Phosphorus (bloody urine or brown urine with red sand ; 
smarting and burning in the urethra, with frequent desire to 
urinate). 

Pareira (taken in doses of four or five drops of the tinct- 
ure at the first warning of the attack of renal colic, especially 
if the latter begins with pain in the glans penis, followed by 
tenesmus of the bladder and rectum ; severe pains down the 
ureters, extending into the thigh ; urine ammoniacal ; parox- 
ysm occurring usually in the early morning from 3 to 6 
o'clock ; pains in the thighs extending down to the feet). 

Sarsaparilla (frequent urging to urinate with scanty but 
painless discharge ; urine slimy, flaky, clayey or sandy). 

Sepia (constant desire to urinate, with painful bearing 
down in the ureters in the morning ; urine turbid with red 
sandy sediment). 



374 DISEASES OF THE RENAL PELVIS. 

Pichi, in renal colic from uric acid calculi, 

Tabacum, when there is collapse from extreme pain, 

Thlaspi bursa pastoris^ in uric acid gravel with hsematuria, 

Other remedies are Nitric or Nitro-muriatic acid, Pulsatilla, 
Sulphur, Benzoic acid, Boro-citrate of Magnesium, Chininum 
sulph. and Sarsaparilla. When the urine is alkaline, Carleton 
advises Phosphoric acid, Phosphorus and Magnesia phos. 

Treatment of Renal Colic. — When this occurs, the patient, 
if not gouty, should be given a hypodermic of 'Morphine if the 
pain is agonizing, as it usually is. Heat tends to relieve the 
pain, and a hot bath is often serviceable. Hot applications to 
the loins should be made if possible, and v the patient should 
drink freely of water, weak tea, hot lemonade or barley water. 
The hypodermic of Morphine may be given in the dose of y& 
to y 2 grain with T f T grain of Atropine sulphate, or, as sug- 
gested by Kichhorst, Morphine hydrochlorate, four and one- 
half grains ; Glycerine and water, each seventy-five minims ; 
mix, and give a hypodermic dose of from four to eight 
minims. To be preceded by large rectal enema. Supposi- 
tories of Opium and Belladonna will palliate the pains. 

Carleton calls attention to the fact that in gouty patients 
the use of Morphine may be the direct cause of instituting an 
attack of gout. The writer knows of one case in which the 
hypodermic of Morphine was said to have been the cause of 
narcosis and death. 

A change of position should be tried by the patient as re- 
lief from pain sometimes follows it. Manipulation of the ab- 
domen is frequently of great service. 

Chlo7 r oform is serviceable in prolonged cases, the pain being 
allayed by frequent whiffs. 

Citrate of potassium may be added to water which the pa- 
tient drinks in doses of from fifteen to thirty grains. 

Glycerin should be given after the acute attack is over in 
doses of from one to four fluid ounces in equal parts of water, 
one dose only daily and between meals. It may cause head- 



TREATMENT OF RENAL CALCULUS. 375 

ache and diarrhoea, hence it is best to begin with doses of 
half an ounce and increase daily. It shortens the attacks, 
lessens or stops the dull lumbar pains frequently remaining 
after the attack, and postpones the returns of the attacks. Its 
use should be discontinued as soon as possible, as it may pro- 
duce acute nephritis. 

For the lumbar pains Phenacetin, Belladonna, Hyoscya- 
mus, Codeine, Sweet Spirits of Nitre, Buchu and Uva ursi 
are recommended by Anders. 

For hemorrhages in the course of renal calculus various as- 
tringents may be given, as fluid extract of Ergot, Alum in 
ten or fifteen-grain doses, Gallic acid in twenty or thirty-grain 
doses ; also, Hamamelis tincture, Trillium or Geranium in 
drachm doses. Tincture of Thlaspi bursa pastoris in half- 
drachm doses continued over a period of weeks may control 
haemorrhage and aid the expulsion of sand. 

The preparation already referred to of corn-silk, broom-tops 
and lithia is useful, in the writer's experience, for allaying 
irritation, increasing the flow of urine and promoting the ex- 
pulsion of uric acid "sand." 

Surgical Treatment. — During renal colic the passage of a 
full-sized steel sound into the bladder is said to favor the 
passage of the calculus by reflex action, causing the ureters to 
dilate and allowing the urine to push the stone into the 
bladder. 

Repeated attacks of pain and the occurrence of pyelitis call 
for removal of stone by surgical means. The success of sur- 
gical treatment for this disorder is now such as make it desir- 
able before the patient becomes a poor subject for operation. 

The writer has referred a number of cases to Dr. Charles 
Adams, and thus far without a single death from operation. 

After the removal of uric acid calculus the von Noorden 
and Strauss treatment of Calcium carbonate, ten to thirty 
grains, three times daily, may be of service in preventing 
further formation. 



376 



DISEASES OF THE RENAL PELVIS. 




Fig. 25. — Renal calculus (actual size) removed 
recovery. 



by Dr. Chas. Adams, with perfect 



URETERITIS. 377 

In cases of anuria from impaction of stone nephrostomy or 
pyelostomy may be performed. The stone may be pushed 
either up or down in the ureter. In advanced pyelonephritis 
nephrotomy or nephrectomy is to be performed. 

Symptomatic Treatment After Operation. — After surgical 
operations to relieve the pains and fever the following reme- 
dies may be indicated : Belladonna, Chamomilla, Digitalis, 
Iyaurocerasus, China, Cuprum, Nux moschata, Nux vomica, 
Veratrum album. 

URETERITIS. 

Definition. — Inflammation of the ureter. 

Etiology. — The same as pyelitis. It must be remembered, 
however, that in the pyelitis secondary to cystitis the ureter 
is often but slightly involved, if at all. 

Pathologic Anatomy. — Similar to that of pyelitis. 

Clinical Features. — In acute ureteritis the features are (i) 
severe abdominal pain, chiefly on one side, beginning in the 
renal region and gradually extending to the bladder ; and (2) 
tenderness and swelling of the vesical end of the ureter, which 
in women can be felt by the finger per vaginam. 

Diagnosis. — The diagnosis must be made chiefly by exclu- 
sion. If there are no evidences of trouble elsewhere, and yet 
the urine contains pus and epithelial debris, especially in 
women, after a cleaiising injection, it may be reasoned that 
the ureter is the seat, at least partially, of the inflammation- 
Often, however, there occurs what is known as renal tenes- 
mus, violent and painful contractions of one or the other 
ureter and corresponding pelvis of the kidney, with marked 
tenderness or soreness under pressure of the latter organ, pro- 
ceeding from morbid irritability of both structures. 

The pains occur in paroxysms, which vary in frequency, 
duration and severity in different cases, according to the stage 
of the preceding ureteritis and the extension of the lesion to 
one or both sides. As a rule, it is confined at first to the 



378 DISEASES OF THE RENAL PELVIS. 

groin on one side of the body, and afterward to the corre- 
sponding lumbar region. In the more severe attacks, the 
pain, besides being violent in these situations, radiates to the 
hip, the outer and inner sides of the thigh, the knee, leg, and 
even to the toes. Cramps of the muscles of the lower ex- 
tremity on the affected side also occur in these severe parox- 
ysms. In the well-marked cases, attacks of this sort come on 
daily, or even several times a day. They are most frequent 
and severe during the menstrual periods. The patients de- 
scribe them as occurring most often during the night. They 
awake with a pressing desire to urinate ; the emptying of the 
bladder is accompanied by more or less pain and spasm, and 
its evacuation is followed by a cramp-like pain, ascending 
along the course of the ureter to the kidney, and radiating to 
the lower extremity. The patient sleeps, as a rule, on the 
affected side, with the face turned toward the pillow, and it is 
the habit of many to draw the opposite thigh up over its 
fellow against the abdomen. The pain is excited in the early 
stages by the marital relation, which in nearly all cases be- 
comes intolerable in the advanced stages of the disease. 

Differential Diagnosis. — To distinguish renal tenesmus 
from renal colic, make pressure over the ureter where it lies 
in the vesico-vaginal septum, or inject the bladder with warm 
water. 

The pressure of the water, when sometimes only a few 
ounces are used, causes an irresistible desire to urinate, which, 
if not promptly relieved, is followed by the pain along the 
ureter and in the kidney, even in the corresponding hip and 
lower extremities, down to the ends of the toes. The patients 
recognize the pain produced in this way as the symptoms 
which have been their chief source of suffering. The attacks 
of renal tenesmus brought on by either of these procedures 
may last for several hours or days, and are frequently accom- 
panied by great mental excitement and hysterical manifesta- 
tions. Hence the necessity of caution in adapting these 
means to the peculiarities of the case. 



URETERITIS. 379 

In chronic cases we find the following : 

1. Increased frequency of urination, greater when standing, 
not absent when lying down. 

2. Bearing-down pain, also increased by standing. 

3. Tenderness felt, and desire to urinate excited when 
pressure is made over the curve of the ureter. 

Prognosis. — Ureteritis without renal tenesmus has the same 
prognosis as pyelitis. With renal tenesmus prognosis is less 
favorable. 

Treatment. — The same as for pyelitis in cases unaccom- 
panied by renal tenesmus. 

For the thickening of the ureters Hydriodic acid has been 
used with apparent benefit in one of the writer's cases, given 
in the form of syrup. 

The treatment for renal tenesmus is surgical, and is called 
kolpo-uretero-cystotomy. An opening through the vesico- 
vaginal septum not smaller than a silver half-dollar is made, 
having specific and close relation to the outlet of the affected 
ureter and kidney. 






CHAPTER XV. 

VARIOUS ABNORMAL STATES OF THE URINE : UTHURIA, OXA- 

LURIA, PHOSPHATURIA, CHYLURIA, HEMATURIA, 

HEMOGLOBINURIA, ETC., ETC. 

Lithuria: Synonyms. — Uraturia, uricaciduria. 

The terms lithaemia and uric acid diathesis are also used 
more or less synonymously with the above. 

Definition. — The voiding of urine containing a brick-dust 
sediment composed chiefly of urates of sodium, potassium, 
etc., and of uric acid. In a large majority of these cases an 
actual relative excess of uric acid in solution is to be found in 
the urine, thus differing from phosphaturia, in which the 
writer usually finds actual diminution of phosphoric acid, 
and from oxaluria. 

According to Sir Henry Thompson, if, without any errors 
of diet, a patient under 40 habitually passes urine which soon 
deposits a pinkish sediment, or which, though clear when 
voided, soon becomes thick and opaque, or covered with a 
delicate film or pellicle exhibiting faintly a play of prismatic 
colors — or if in a few hours there is seen in the sediment a 
deposit of free uric acid — " red-pepper crystals " — there is un- 
doubtedly an undue tendency, either inherited or acquired, to 
produce uric acid. 

The sediment occurs under various physiological conditions 
— as, for example, in winter, when the urine for any reason 
is concentrated or highly acid. It is found in a large number 
of diseases of which acute inflammatory diseases, as rheumatic 
fever, the crisis in continued fevers, renal congestions, and 
various hepatic disorders are most prominent. 

It has lately been pointed out by Dr. C. Bartlett, in a paper 



"uric acid diathesis." 381 

on " The Clinical Relations and Diagnosis of the Uric Acid 
Diathesis," that the diagnostic value of the discovery of uric 
acid sediments in the urine depends entirely upon the associated 
clinical phenomena and the life-history of the patient. Such 
sediments, as he shows, are found where there is not necessarily 
an excess of the acid ; they are very common in normal urine 
which has been allowed to stand for more than twelve hours; 
where the urine is highly concentrated or excessively acid ; 
where there has been free indulgence in highly nitrogenous 
diet or in rich food ; in cases where there is relative or abso- 
lute hepatic insufficiency ; also in the profuse pale urine, with 
low specific gravity in the neurotic and hysterical, where the 
absence of the usual urinary pigments tends to precipitate the 
uric acid. As he further points out, any deficiency in the ox- 
idation-changes in the system causes an increase in uric acid 
deposits, which are accordingly found in connection with car- 
diac and respiratory disorders, and in cases of post-nasal ade- 
noids ; also in many liver affections, due here to deficient oxi- 
dation of waste matters. 

The presence, therefore, of these uric acid sediments in the 
urine is not diagnostic of the condition called so frequently the 
uric acid diathesis, except where a careful examination reveals 
the presence of the essential characteristics of gout at some 
time in the history of the case, or a well-marked gouty an- 
cestry. 

According to Richardson, in gouty people there is an exag- 
gerated tendency to premature deposition of uric acid from 
the urine, and the degree of this exaggeration may be esti- 
mated by preserving specimens of the urines of several days 
(of twenty-four hours) in corked phials in a warm place, as 
the warmth checks the deposition of amorphous urates, and 
guarding from fermentation and putrefaction by adding a few 
drops of chloroform. Should crystals appear in the course of 
a few hours, regularly, this shows a tendency to gravel, or 
the uric acid diathesis ; should no uric acid be thrown down 



382 ABNORMAL STATES OF THE URINE. 

in the first twelve to twenty-four hours or more, the absence 
of such tendency is quite probable. 

According to Wyeth, the presence of uric acid crystals in 
urine which has not been passed more than three or four 
hours has a pathologic significance scarcely less than oxal- 
uria, and hence is a contra-indication to a serious surgical op- 
eration. 

Pathology. — According to Croftan, whatever the primary 
or remote cause, the nature of the taint remains excessive 
nuclein-catabolism — i. e., a tendency on the part of the uratic 
subject to disintegrate a quantity of nuclein in excess of the 
normal. At first the normal oxidation processes are capable 
of converting almost all the nuclein into uric acid, which is 
duly excreted by the kidneys ; at the same time small quan- 
tities of the poisonous alloxuric bases are formed ; they enter 
the circulation and pass through the kidneys, exercising all 
the while the toxic influence they are capable of exerting — i. 
e., they produce a variety of functional disorders and probably 
lay the foundation of the anatomical changes they can pro- 
duce in the kidney parenchyma. As the self-intoxication 
progresses in severity, vital processes fall below par and there- 
with oxygenation is reduced. This adds a second factor to 
the primary cause of the trouble, because with deficient oxy- 
genation even less of the nuclein that is being disintegrated 
in excessive quantity can be converted into innocuous uric 
acid, and more of the toxic alloxuric bases are necessarily 
formed in its stead. While oxidation is still up to par, uric 
acid is excreted in increased quantity ; as oxygenation grows 
more and more deficient the excretion of uric acid diminishes. 
The sum of uric acid and alloxuric bases excreted, however, 
remains uniformly high at this stage. As the disease pro- 
gresses in severity, whether in the natural course of the afflic- 
tion or aided by indiscretions in the mode of life, diet, alco- 
holic excesses, etc., the perversion, too, progresses in sever- 
ity, more alloxuric bases are formed, and the process of 



"uric acid diathesis." 383 

chronic intoxication goes on. It is during this period that in 
all probability the inflammatory and necrotic changes occur 
in the joints, kidneys and elsewhere that prepare a field for 
the formation and deposit of urate concretions. Virchow calls 
attention to the analogy that exists between the distribution 
and localization of these urate deposits and the manifestly 
secondary deposits of calcareous matter found in a variety of 
chronic diseases. The urate concretions themselves act as 
local mechanical irritants and may, of course, just as any 
other foreign body, set up what we may call tertiary inflam- 
matory changes in the joints and kidneys. In the last stages 
of the intoxication, finally, where cachexia is extreme, oxy- 
genation reduced to a minimum, where destructive tissue 
changes have taken place, the formation of uric acid ceases 
altogether, and only alloxuric bases are poured into the blood 
in proportion to the (reduced) quantity of nuclein that is still 
being disintegrated. At this period both the excretion of 
uric acid and the formation of urate concretions ceases ; the 
alloxuric bases are excreted in large quantities. Finally, the 
kidneys become incapable of excreting any of the solids, and 
acute alloxuraemia, "uraemic poisoning," leads to the exitus 
lethalis. 

In outline this may represent the pathogenesis of so-called 
uric-acid lesions. Certain cases remain stationary and never 
progress further than the stage of functional disorders, with 
increased excretion of alloxuric bases ; others gradually enter 
the stages of concretions — i. e., gout, nephritis, etc.; only a 
small part reach the terminal stage. 

Clinical Features. — These are essentially as follows : 
i. Mental irritability or depression, and easily induced ex- 
haustion. 

2. Headaches, insomnia, or restless sleep. 

3. In some cases more or less persistent pain above the 
symphysis pubis like a neuralgia. 

4. More or less frequent attacks of lumbago. 

5. Various gouty phenomena. 



384 ABNORMAL STATES OF THE URINE. 



TREATMENT OF LITHURIA. 

Hygiene. — The patient is to avoid tobacco, alcohol, sweets 
and excess of nitrogenous foods, to drink freely of soft water, 
and to get as much fresh air and moderate exercise as possible. 
Bicycle riding, not carried to excess, is certainly good, as also 
golf, automobile riding and horseback riding. 

The patient needs much sleep in a well-ventilated room. 
The sleep of lithsemics is likely to be a restless one, but it 
frequently happens that after a restless night a patient may 
enjoy a restful slumber, between the hours of six and nine in 
the morning. On this account he should not arise early, un- 
less it is absolutely necessary. Barly rising is as a rule bad 
for lithsemics, who in many cases are at their worst in the 
early morning. Massage, hydrotherapy and electrotherapy 
may be used for their tonic effect. 

In support of the writer's experience is the clinical view of 
Tyson, who says : 

"An abundance of alkaline water, especially between meals, 
or, in the absence of alkaline waters, of plain water, and the 
exclusion of proteid foods to a degree sufficient to eliminate 
uric acid from the urine, accompanied by a liberal amount of 
out-door exercise, is to-day, as for some time past, the treat- 
ment of the uric acid diathesis in whatever form it manifests 
itself. Moreover, as the condition constitutes, as it were, a 
peculiarity of the individual which, while capable of being 
held in check, is scarcely eradicable — especially in hereditary 
cases — the treatment must be kept up for a long time, 
indeed in certain cases never interrupted, except for a short 
time, for the condition is almost sure to reassert itself. For 
articular deposits and swellings, massage is the most valuable 
treatment, especially when taken in connection with warm 
baths." 

Diet. — The patient should avoid coffee and beer. The 



URIC ACID IN FOODS. 385 

latter especially in the writer's opinion is very injurious to the 
lithsemic. The liver, spleen, thymus glands, and kidneys of 
animals are forbidden. Raw meats and smoked meats con- 
tain the extractives, and are consequently not suitable articles 
of diet for a uratic case. Soups, meat extracts, sauces, etc., 
are especially unsuitable, as they contain the extractives in 
concentrated form ; boiled, stewed, and fried meats of all 
kinds, on the other hand, are permissible. 

Eggs and milk are suitable food ; it is true they are both 
rich in nucleins, but of a different kind to those found in the 
internal organs and in the blood. (Croftan.) 

In the writer's opinion it is not wise to forbid meat al- 
together, as Croftan says : 

" Proteids produce a transitory digestion leucocytosis, and 
should in consequence be interdicted on the theoretic grounds; 
the bad effects, however, that might be postulated from these 
for a uratic case are fully counter-balanced by the good effects 
in the direction of increased nutrition and resisting powers 
that accrue from an animal diet. Some discrimination will 
have to be exercised according to individual idiosyncrasies, 
and a great deal will depend upon the kind of proteid food 
and its mode of preparation." 

The following table, quoted by Carter, is of interest : 

URIC ACID IN FOODS. 

Uric acid and Xdnthins: 
Substance. Percent. Grains per lb. 

Lamb (cold roast leg), 0500 3.50 

Soup (made from bones), 0068 0.48 

Soup (made from meat), 0202 1.40 

Hospital beef -tea (cooked 8 hours), . . . .0980 7.00 

Saddle of mutton, .0200 1.40 

Mutton (cold roast leg), 0160 1.10 

Veal (cutlet), 0490 3.50 

Beef (cold sirloin), 0160 1.10 

Kidney of Sheep, . .0490 3.50 

Liver of Sheep, 0910 6 50 

Fowl (breast), 0240 1.70 

25 



386 ABNORMAL STATES OF THE URINE. 

Uric acid and Xanthins : 

Substance. Percent. Grains per lb. 

Rabbit, 0150 1.00 

Mackerel, 0320 2 00 

Mackerel (boiled 15 minutes), 0150 1.00 

Plaice, 0039 0.20 

Herring (fresh), 0040 0.20 

Herring (Loch Erne, kippered), . . . .0900 6.40 . 

Herring (bloater), 0310 2.20 

Beefsteak (treated raw), 0190 1.30 

Meat juice, 6970 49.70 

Meat extract, ... 8830 63.00 

Tea, 2.5000 175.00 

Coffee, 1. 0000 70.00 

Cocoa, , . .8400 5900 

Eggs, however, do not agree with many, nor does milk. 
Some caution must be observed in regard to these articles, not 
on theoretical grounds, but because of the difference in the 
digestive power of patients. Raw eggs whipped in cream 
may usually be allowed. There are also those patients who 
should be forbidden heavy meats, cheese, ripe peas and beans. 

In most cases milk, with whole wheat bread thoroughly 
baked, rice, oatmeal, barley and rye meal, and fruits, will 
constitute an ideal diet. 

In general the food should be sufficient for proper nourish- 
ment only, the proteids being made up from the lighter meats. 

Yeo suggests a simple dietary of pounded meat and plenty 
of hot water. 

Hygiene and Climatology. — The lithsemic patient needs 
air. Open windows at night, fresh air in the daytime, 
bicycle-riding and mountain-climbing are of the utmost value. 
The amount of exercise is to be regulated by the pulse. 
Those with a slow, but not tense, pulse can endure with im. 
p unity exercise which would be violent and dangerous for 
others. 

Change of climate is beneficial. In the writer's experience, 
dry, mountainous regions are preferable to the seashore. The 
author's favorite prescription for lithsemics is two weeks at 



TREATMENT OF " URIC ACID DIATHESIS." 387 

Saratoga, with drinking of Congress or Hathorn water, fol- 
lowed by three weeks in the mountainous portion of the Adi- 
rondacks, at either Lake Placid, Adirondack Lodge or St. 
Hubert's Inn, according to the tastes of the individual. A 
week at each one of the above-named places is advisable for 
those unfamiliar with the Adirondacks, so that in subsequent 
visits the one best-liked may be selected from experience. 
Lake Placid is enjoyed by those who like a beautiful moun- 
tain lake with extensive views ; Adirondack Lodge by those 
who prefer to be in the heart of a primeval forest in the foot- 
hills of the highest mountains, and St. Hubert's by those who 
like the diversity of valley, mountains, lakes and forests. 
While the Adirondacks are well known to those in the East, 
the benefits of their climate are comparatively unknown to 
Western people. Not of little importance is the purity of the 
spring water in the mountain regions named above. An ad- 
ditional advantage is the proximity of chains of lakes .where 
those fond of boating and fishing can find all they desire. 

Mineral Waters. — For the lithsemic, waters containing 
sulphate of soda are by far the best ; alkaline waters, like Vals, 
Vichy, etc., may cause the urinary sediment to disappear 
temporarily, but their curative range is limited. The best 
known sodium sulphate waters are Pullna, Hunyadi Janos, 
Friedrichshall, Marienbad, Carlsbad, Rubinat, and Kronen- 
quelle. 

The full dose of Hunyadi Janos is from five to seven ounces 
taken an hour before a light breakfast, during which a cup or 
two of some hot liquid is to be taken. 

Marienbad water is far more agreeable than Hunyadi 
Janos, since it contains no sulphate or magnesia. Dose, half 
a pint or more. Carlsbad contains no magnesia. It is best 
suited to robust patients. 

Sir Henry Thompson recommends Carlsbad water to which 
a little Hunyadi Janos is added. From four to seven ounces 
of Carlsbad at a dose, heated, to which as much Hunyadi 
Janos is added as is demanded by the bowels of the patient. 



388 ABNORMAL STATES OF THE URINE. 

In America the best saline waters are probably the Con- 
gress and the Hathorn, although others are now found in 
Arkansas which may prove valuable. 

Searle thinks highly of an effervescing draught composed 
of dilute lemon-juice and bicarbonate of soda. A solution of 
Carlsbad salt and lithium benzoate has been recommended, 
and theoretically should be useful in several ways. French 
Vichy water certainly is of service in causing disappearance 
of the sediment and when there is indigestion and flatulence 
together with constipation. Allouez, Bear and Londonderry 
lithia waters are certainly serviceable 

The Londonderry charged water is especially popular ow- 
ing to its well-known effervescent properties. 

Remedies. — The principal ones are Bryonia, Cimicifuga, 
Colchicum, Lithium, Lycopodium, Nux vomica, Mercurius 
dulcis, Sodium glycocholate, Ferrum, Arsenicum, Oxygen gas, 
Sodium phosphate, Sarsaparilla, Hedeoma, Uranium nitrate 
and Ocimum. 

Lithium compounds are used very extensively in the uric 
acid diathesis. White Rock Lithia water, Lithia tablets and 
Lithium benzoate have been used by the writer for dissolving 
the sediment of urates and for increasing the ratio of urea to 
uric acid in the urine. 

The preparation known as Thialion, containing lithia and a 
saline laxative, is given in teaspoonful doses in a glass of 
water an hour before meals. 

Lithium benzoate (2 to 10 grains) is satisfactory ;n dissolv- 
ing the sediment of urates and increasing the urea-uric acid 
ratio in cases where the digestion is good and the stomach 
tolerates it. 

Dilitte Nitromiwiatic acid (5 to 7 drops) in cases where 
hepatic symptoms are prominent. 

Cimicifuga in drop doses of the tincture, for the lumbago 
of lithsemics, may be given, together with White Rock lithia 
water, which is an excellent water in cases of lumbago. 



TREATMENT OF " URIC ACID DIATHESIS." 389 

Gelsemium tincture is also serviceable for trie myalgia. 

For the lumbago so commonly occurring in lithsemics a por- 
ous plaster to support the muscles and furnish warmth, or 
rubbing with a liniment, as of Chloroform and Aconite, or the 
use of static electricity may also be of service. 

Hedeoma polegioides, according to Paul Allen, produces 
the symptoms of lithsemia. It has been proved to be of clin- 
ical value by Carleton. There is the characteristic mental 
depression, flatulency and dragging pains of the lithsemic con- 
dition. 

Nux vomica is serviceable in constipated subjects and when 
the usual indications are present. Nux and Calcarea carb. or 
Phos. are good remedies for lithsemic children, in the third 
decimal. 

Glycerophosphates. — The Lithium Glycerophosphate may be 
given when, in addition to the low urea-uric acid ratio, we 
find also a high ratio of urea to phosphoric acid. In such 
cases nervous depression and insomnia are features. 

Acidum hydrochloricum. — Hydrochloric acid in two-drop 
doses after meals, in water, may be given those patients whose 
lithsemic condition is due to the imperfect digestion of pro- 
teids from a lack of hydrochloric acid in the gastric juice. 

Sodium phosphate. — This is the best laxative for many 
lithsemics ; to be taken in thirty-grain doses in half a glass of 
water on rising and on retiring. 

Iron and Arsenic. — Croftan believes in treating lithsemia as 
a secondary ansemia, with Blaud's pill separately, and Fowler's 
solution in combination with medullary glyceride or hsemabo_ 
loids. In those cases of lithsemia where the gastric disturb, 
ances are neurosal in form, and accompanied by pain, often 
neuralgic in character, sour stomach and eructations, give the 
Fowler's solution in three-drop doses after meals. 

Oxygen. — Croftan finds most gratifying results from inhal- 
ation of oxygen gas as follows : The gas is procured in cylin- 
ders. At each treatment about five gallons are allowed to 



390 ABNORMAL STATES OF THE URINE. 

stream into a rubber bag with two stopcocks, and trie patient 
inhales through a rubber tube and glass mouthpiece from the 
bag. Those physicians who are located at a distance from 
large centres, and who cannot obtain the gas in cylinders, can 
readily procure a simple form of oxygen retort and gasometer 
and generate their own oxygen at a very small expense. The 
patient is instructed to exhale thoroughly, then to fill the 
lungs with oxygen, to remove the tube, and to breathe a little 
more air until the chest is expanded to its fullest capacity. 
He is then instructed to hold the gas as long as possible and 
then to exhale slowly. This operation is repeated until the 
prescribed quantity of oxygen has been taken. By this 
method the gas is held for a time under pressure and the 
maximum absorption obtained. In the beginning inhalations 
are given daily, later every other day, and finally twice a 
week. Treatment should be given for a period of at least 
three months. 

Dr. Croftan says the most striking results have been ob- 
tained in acute cases by inhalations of oxygen gas. On six 
occasions he claims to have aborted an attack of gout by inhal- 
ations of oxygen repeated at short intervals. He believes, too, 
that he can invariably relieve, if not cure, a uric-acid head- 
ache, a migraine, in short, lithsemic attacks, by oxygen inhal- 
ations. 

oxaeuria. 

Definition. — The voiding of urine containing crystals of 
calcium oxalate, while at the same time the patient complains 
of certain nervous or digestive troubles, or both. The deposit 
is not necessarily associated with increase in the total quantity 
of calcium oxalate in the urine. 

Associated Disorders. — Jaundice, spermatorrhoea, disturb- 
ances of digestion and neurasthenia. 

Etiology and Pathology. — The origin of oxalic acid in the 
body is obscure, and the quantity of it in the urine is not in- 



OXALURIA. 391 

dicated by the number of crystals in the sediment. The acid 
sodium phosphate of the urine holds the substance in solu- 
tion, and the crystals form during progressive decomposition 
of the phosphate. Certain articles of diet, as apples, tomatoes, 
bananas and rhubarb favor their formation, and, in the spring 
of the year, when rhubarb is eaten, the writer finds always an 
increase of the oxalate crystals in samples of urine examined. 
Clinical Features. — These are usually the following : 
i. Digestive disturbances, particularly flatulence. 

2. Inability to retain the urine when desire for micturition 
comes. 

3. Mental and physical fatigue from slight exertion ; list- 
lessness. 

4. Nervous symptoms : headache, wakefulness, mental de- 
pression, hypochondria. 

5. Backache or lumbar pain, generally on one side, and 
sometimes severe ; perhaps due to mechanical irritation of 
ureter by the crystals. 

6. Acute intercurrent attacks of prostato-urethritis, perhaps 
due to irritation from the crystals. 

The Urine. — According to Heitzmann the typical condition 
of the urine is as follows : 

1. Quantity per 24 hours : decreased. 

2. Color. — Increased. 

3. Reaction. — Acid. 

4. Specific Gravity. — High, 1.025 or upwards. 

5. Sediment. — Crystals of the oxalate occurring as octa- 
hedra, disks, spheres or dumb-bells. 

Some authors hold that the crystals are found mainly in 
alkaline urine, but the writer has shown by a large number 
of analyses that this is not true. 

The writer finds a sediment of calcium oxalate very com- 
mon in diabetes mellitus, and it is said that oxaluria may be 
followed by glycosuria. 

Patients who have sediments of urates or uric acid in their 



392 ABNORMAL STATES OF THE URINE. 

urine frequently show oxalate either accompanying the former 
or alternating with them. 

The chief danger in these cases is the possible formation of 
calculus. In the writer's experience, confirmatory of Dr. 
Beale's statement, the dumb-bell crystals are to be regarded 
as minute calculi. For example, in January, 1898, a patient 
complaining of lumbar pain brought urine for examination : 
dumb-bell crystals, octahedra and concretions were found in 
the freshly-voided urine. Diagnosis of oxalate calculus was 
made, and in March the patient voided a small rough stone of 
that variety. 

In a number of cases, however, where the dumb-bell crys- 
tals have been found by the writer no history of calculus has 
as yet been obtained, nor symptoms noticed. 

In general the oxalate sediment is a sign of impaired diges- 
tion, hepatic or intestinal. 

Relation to Surgical Operations. — According to Wyeth the 
presence of oxaluria is a contra-indication to a serious surgical 
operation, for the reason that it is pathognomonic of a disturbed 
nutrition due to insufficiency of the digestive fluids and to fer- 
mentative processes in the intestinal tract. 

Williams thinks that the excretion of oxalate crystals by 
the kidney may, by irritation, lead to true nephritis. 

TREATMENT OF OXAEURIA. 

Climate and Hygiene. — The oxaluric patient does better in 
dry climate. He should avoid damp or clayey soil and sleep 
as high from the ground as possible. Camping out in the 
mountains of the West has repeatedly been of benefit to my 
oxaluric patients. The sea-shore is not so well suited to 
them. 

A cold compress over the abdomen at night, as recom- 
mended by Ralfe, has relieved some of the writer's cases in 
which flatulence was complained of. 



TREATMENT OF OXALURIA. 393 

Diet. — Patient should avoid articles of diet rich in oxalic 
acid, as apples,' bananas, rhubarb, tomatoes, etc.; all sweets and 
sweet or carbonated drinks, such as are usually sold at soda- 
fountains, and indigestible materials generally. Hard water 
is to be avoided. Distilled water is probably the best drink. 
Diet composed chiefly of meat is thought to be best. The 
patient may take stale bread, fresh roe, and the brains of 
animals, but should avoid tea, coffee, and alcoholic drinks. 

Remedies. — The principal remedies are dilute Nitrohydro- 
chloric acid, Basham's mixture, Hydrangea, Oxalic acid, Kali 
sulphuricum, Senna and Berberis. 

Acidum nitromuriaticum is a frequently employed remedy 
in cases of young men with sediment of oxalate crystals in the 
urine and complaining of malaise, great repugnance to mental 
and physical exercise, and depression of spirits. 

In each case make up a fresh preparation of dilute 
Acidum nitromuriaticum as follows: Mix Nitric acid, four 
parts by weight, with Hydrochloric acid, fifteen parts by 
weight, in a large glass beaker. When effervescence has 
ceased, add seventy-six parts by weight of distilled water and 
mix well. Give five to seven drops of this freshly-prepared 
acid three times daily, after meals. It is held by some 
authorities that after mixing the strong acids the mixture 
should stand four weeks, until it turns brown, before dilution 
and administration. 

Lysidin is properly a uric solvent but it has apparently 
helped one or two cases of oxaluria in the writer's practice. 
It may be had in form of 50 per cent, solution, the dose of 
which is usually ten drops three times daily. The indica- 
tions for Lysidin are said to be irritability of the bladder, ir- 
regular heart action, and nervous symptoms. Its action is 
usually speedy, which is fortunate, owing to the cost of the 
substance. The dose should be well diluted with water. 

The two cases in which I have used it were very different 
in character, one being a young man whose affection was com- 



394 ABNORMAL STATES OF THE URINE. 

paratively recent, the other in an older man with a long-stand- 
ing oxaluria. In the second case the distressing pain in the 
lumbar region was apparently relieved by a few doses of a few 
minims of the agent, after having persisted for a number of 
days. The second case is particularly worthy of mention, as 
various measures had failed to relieve the pain in the past, 
and also during the present attack. 

Both patients however, were rather skeptical as to the value 
of the remedy despite the fact of their improvement. 

Basham's tincture in doses of from two to four teaspoonfuls, 
and tincture of Hydrangea in ten-drop doses have been recom- 
mended. 

From a strictly homoeopathic standpoint oxalic acid in 
potency is said to be curative and adapted to those cases in 
which there is burning during micturition, and backache. 

Kali sulphuricum is used by Hserman, of Paris, and was 
indorsed by the late T. F. Allen for oxaluria. 

PHOSPHATURIA. 

Definition. — Clinically, by phosphaturia we mean the void- 
ing of urine containing a phosphatic sediment. The term 
" excess of phosphates " is used synonymously, but if this 
means excess of the total P 2 5 in the urine it is incorrect, for 
only in rare cases do we find this excess, and to such cases the 
term phosphatic diabetes has been given, when the quantity 
is far above three grammes per twenty-four hours. 

Etiology. — The cause of the sediment is deficiency of acid- 
ity on part of the urine, with sometimes a relative excess of 
earthy phosphates, as compared with alkaline ones. 

The causes of persistently alkaline urine are as follows : 

i. Food or drink abounding in alkaline salts, as alkaline 
mineral waters. 

2. Indigestion due to hypochlorh; dry. 

3. Ammoniacal fermentation of the urine in the renal pel- 
vis or bladder. 



PHOSPHATURIA. 395 

The disorder is therefore either functional or secondary ; it 
also occurs in cases of chronic prostatitis with prostatorrhoea. 
Clinical Features. — These are usually the following : 

1. Mental and physical weakness. 

2. Backache and sexual weakness 

3. Neurasthenic or hypochondriacal symptoms. 

The writer has, however, seen obstinate cases* in which no 
symptoms at all other than the condition of the urine were 
complained of, but the sediment in the urine caused anxiety 
on part of the patient. 

The chief danger in these cases is the formation of calculus. 

The Urine. — The essential features of the urine are as 
follows : 

1. Color not increased, usually diminished to lighter than 
normal. 

2. Urine turbid when freshly voided. 

3. Reaction less acid than normal ; may be neutral or al- 
kaline. 

4. The urine, when heated, becomes cloudy, but the cloud- 
iness disappears in great part when five or ten drops of 20 per 
cent, acetic acid are added, care being taken to shake the tube 
after such addition. At the same time effervescence may be 
noticeable. 

5. The urine on standing deposits an abundant whitish 
flocculent sediment. Removed with a pipette, this sediment 
is more or less soluble in 20 per cent, acetic acid. 

6. In some cases the sediment is so abundant as to pass out 
at the end of urination as a white or creamy mass, alarming 
the patient, who mistakes it for semen. 

TREATMENT OF PHOSPHATURIA. 

Diet and Hygiene. — The patient should avoid hard water 
and in general adopt a nutritious diet ; he should have as 
much sleep and exercise in the open air as possible. Change 



396 ABNORMAL STATES OF THE URINE. 

of climate often helps. Sexual intercourse is undoubtedly 
bad for those affected with phosphaturia and should be re- 
stricted to a minimum, or altogether forbidden. 

Remedies. — The principal remedies are Uro tropin, Nuclein, 
Arsenicum, Boracic acid, the Hypophosphites, the Glycero- 
phosphates, China, Phosphoric acid. 

Urotropin is a valuable remedy in this condition in some 
cases acting very speedily. Dose, from five to ten grains in 
water, two to four times daily. 

There are cases, however, in which it effects but relative 
improvement. Such cases need attention to the digestion and 
general health or removal of calculus if one be present. 

Nuclein. — Inasmuch as phosphaturia is thought to be due to 
destruction of the nucleus of the leucocytes nuclein is advised 
in the therapy of this disorder. Its efficacy is said to be dem- 
onstrated within twenty-four hours, when an examination of 
the urine will reveal a decrease in the phosphates, and an 
examination of the blood will reveal that the number of 
lymphocytes is the predominant number of white corpuscles 
within the blood. 

Arsenicum. — One of the worst cases of phosphaturia which 
the writer ever saw, with severe digestive disturbances, nausea, 
vomiting, and pain under the ribs was cured by three drops of 
Fowler's solution four times daily, Marienbad salts being 
also administered in the morning and at night, and lithia 
water taken as a beverage. 

Boracic acid. — In cases where the sediment is very dense 
and the formation of calculus is feared the writer has been 
able to keep the urine in tolerably good condition by Ralfe's 
formula : 

Boracic acid one hundred and twenty grains, glycerine one 
fluidounce, warm water eight fluidounces. This, in tea- 
spoonful doses, usually suffices to clear the urine. It should 
be made up fresh from time to time. The sediment may, 
however, return after its use is discontinued, unless in the 
meantime the patient's general health improves. 



CYSTINURIA. 397 

For the phosphaturia which sometimes persists after cys- 
titis, injections of citric acid, five to ten grains in a pint of 
warm water, are recommended. 

Following the paper of Robin in 1894 the writer called at- 
tention to the theoretical value of the glycerophosphates in 
phosphaturia. The wine of phosphogly cerate of lime, con- 
taining ten grains per fluidounce, is prescribed in doses of a 
tablespoonful or two, two or three times daily, at meals. 
Where alcohol is contra-indicated the syrup may be given in 
the same dose, or the capsules (four grains) in doses of one 
capsule three times daily. The dose of the above for children 
is one-half. 

The acid glycerophosphates have been serviceable in one 
case which the writer has treated. 

Acidum phosphoricum. — This agent by improving digestion 
and also acidifying the urine may be of service in phosphaturia. 
Use the first decimal. 

For cases where there is marked deficiency of phosphoric 
acid with or without phosphatic sediment, as in neurasthenia, 
Addison's disease, etc., the writer gives the phosphoglycerate 
of lime, or a calisaya and phosphorus mixture, preceeded if 
necessary by mild purgation. 

In obstinate cases Eichhorst suggests the following: Hy- 
drochloric acid seventy-five minims, water six and a half fluid- 
ounces ; one tablespoonful every 7 two hours. The remedy 
should be used for a long time. 

It is quite possible that some few obstinate cases of phos- 
phaturia are due to non-suppurative pyelitis and decomposi- 
tion of the urine in the pelvis of the kidney. Catheterization 
of the ureters or use of the segregator will determine whether 
the urine decomposes in the kidneys or in the bladder. 

CYSTINURIA. 

The occurrence of cystin in the urine is usually noticed 
after infectious diseases, in articular rheumatism and in syph- 



398 ABNORMAL STATES OF THE URINE. 

ilis ; the condition is also often peculiar to families. The 
diagnosis is made by the observation of crystals in the urine 
in the form of six-sided plates like uric acid, but the murexid 
reaction cannot be obtained with them. (See Urinary An- 
alysis, third edition.) 

An odor of sulphuretted hydrogen noticed in stale urine in 
which there is no pus should direct attention to the possible 
presence of cystinuria. 

The chief danger is that of formation of calculus. 

The treatment consists of a diet of fresh meat and green 
vegetables, repeated colon flushings and administration inter- 
nally of mineral acids and Salol. 

OTHER ABNORMAL STATES OF THE URINARY SECRETION. 

There are a number of abnormal conditions of the urine 
which can hardly be classified as separate diseases, but should 
rather be deemed accompaniments of various disorders. 

Albumosuria. — The voiding of album oses in the urine; this 
occurs in septic conditions, during pus formation in the body, 
in osteo-malacia, myxcedema and multiple bone tumors. 

Albuminuria. — The voiding of serum albumin in the urine. 

Alkaptonuria. — In pulmonary tuberculosis and after the ad- 
ministration of salicylic acid the urine on standing may be- 
come brown or red. Addition of potassium hydrate solution 
to the fresh urine causes immediate appearance of the color. 

According to Eichhorst, Antipyrin may be given as a rem- 
edy, as follows: Antipyrin, 15 grains; sugar, 7^ grains; 
make ten powders ; dose, one powder every three hours. 

Syphilitic cases may be treated with Mercurial Inunctions 
and Potassium Iodide. 

Chyluria. — The voiding of urine containing chyle, which 
occurs in minute particles in suspension in the urine, giving 
it a milky or opalescent appearance. It is due to the parasite 
filaria sanguinis hominis, or to obstruction of the thoracic 



CYSTINURIA. 399 

duct. The disease is endemic in the Orient, and is now at- 
tracting much attention ; it also occurs in the West Indies, 
Cuba and Brazil, and we may expect to see cases of it now in 
this country in those who have returned from our new posses- 
sions. There is polyuria and the urine contains albumin, 
fibrin and blood-corpuscles. Coagulation of the chyle in the 
pelvis of the kidney may cause renal colic, and in the bladder 
may cause cystitis. In the latter case the mass must be dis- 
solved by injections of an alkaline solution and withdrawn by 
the catheter. No other symptoms occur, unless the parasite 
becomes diseased, in which case general debility ensues. 
Death from the affection itself rarely occurs. 

Fibrinuria occurs in the above sometimes in clots from 
hsematuria, and rarely as a component of spiral membranes in 
membranous ureteritis. 

Diacetic-aciduria occurs in diabetes where it is a sign of 
coma, and in febrile diseases of children, where it is un- 
important ; the urine contains diacetic acid and gives a red 
color with solution of ferric chlorid. 

Glycosuria. — See diabetes mellitus. 

Hceniaturia. — The voiding of urine containing blood-cor- 
puscles. The source from which the blood is derived is not 
always easy to determine. The following method of diagnosis 
is useful : 

When blood is found in the urine and doubt as to its origin 
or significance exists, recourse is to be had to the following 
clinical measures : 

i. Examine the blood of the patient for parasites, especially 
the plasmodium. 

2. Examine the urine both when blood is absent and when 
present. Dilute the urine with several times its volume of 
water in order to dissolve the blood and to reveal the presence 
of bits of growth. 

3. Examine the bladder with sound and cystoscope. 

4. Make physical examination of the region of the kidneys 
for presence of tumor. 



400 ABNORMAL STATES OF THE URINE. 

5. Look into the family history and the history of the 
patient for haemophilia and examine the patient for superficial 
purpura. 

6. Inquire into the possibility of intoxication by alcohol or 
chemical factors. 

7. Ascertain whether there has been venereal disease or in- 
jury. 

8. Examine the patient's sputum and urine for evidences of 
tuberculosis; also examine the testicles and seminal vesicles 
for evidences of the same. 

In cases when the above are all negative the diagnosis by 
exclusion refers the haemorrhage either to calculus as a cause 
or to early stages of a growth. 

Appearance of Blood in the Urine. — From the kidneys : 
usually well mixed, slight in quantity in nephritis, profuse 
when from growths or diseases of the renal pelvis. In 
nephritis the blood gives the urine a smoky hue. 

Haemorrhage from a ureter is manifested by long clots, like 
earth-worms in size and shape. Hematuria may alternate 
with normal urine when the passage is stopped. Blood from 
the bladder appears in large irregular bright red blood clots 
(sometimes dark brown, if urine quite alkaline) at the end of 
micturition. If the bladder is washed out with borax solution, 
until what comes away is clear, and the solution is again in- 
jected at once, it will come away bloody. Blood from the 
prostate appears toward or at the end of micturition, which is 
usually difficult. Bright blood from the anterior urethra is 
passed at the beginning of micturition or during the intervals, 
or can be stripped out. From the posterior urethra it is 
usually slight in quantity and conies at the beginning or 
end of micturition or both, sometimes clotting. Pink semen 
indicates a haemorrhage from the seminal vesicles. Blood 
from the vulva, vagina or uterus is readily distinguished by a 
history of menstruation, by inspection, by washing, and if 
necessary by catheterization. 



HEMATURIA. 401 

Hematuria is due (a) to injury of the urinary tract, includ- 
ing injury from parasites and stone ; (b) to the effect of drugs ; 
(c) to inflammations ; (d) to growths, syphiloma and tubercle ; 
(e) to congestion, especially from cardiac disease. 

The treatment is, if symptomatic, by administration of such 
remedies as Cantharides, Millefolium, Ipecac, Crotalus, La- 
chesis, Terebinth and Thlaspi bursa pastoris. Rest and liquid 
diet are advisable. In cases where the clots do not pass, 
catheterization may be necessary, but often a clot acts as a 
foreign body and ammoniacal decomposition of the urine re- 
sults in dissolving it. 

Carleton advises continuous catheterization, when the bleed- 
ing is excessive. The condition may yield to ten grains of 
Calomel and of Jalap, each taken at one dose. 

In some cases perineal cystotomy is necessary, with contin- 
uous drainage to remove the clots. 

Hemoglobinuria (passage of blood-coloring matter with few 
or no corpuscles) may be due to secondary degeneration from 
tuberculosis and syphilis, or the dyscrasia and cachexia of can- 
cer, infectious diseases, purpura, scurvy and malaria. 

It is most commonly seen by the writer in children or in- 
fants with scurvy from artificial foods, and as a result of 
malaria. Connective tissue shreds are very abundant in the 
urine of children with scurvy, and there is a little albumin 
and a few casts at times. Severe cases present chill, some- 
times preceded by colicky pains in the abdomen ; subnormal 
temperature during the chill, nausea, vomiting, pain in the 
back and limbs, and retraction of the testicles ; exhaustion, 
headache, thirst, coma, and sometimes jaundice or urticaria 
may follow. There is a tendency on part of the disorder to 
be paroxysmal ; even in cases due to scurvy there will be days 
when the urine is free from the reddish deposit. It may ap- 
parently cease altogether, but return again after weeks or 
months. It is said that there is danger of termination in ne- 
phritis. In the new-born the disease may be epidemic in cer- 
tain localities, and dangerous. 
26 



402 ABNORMAL STATES OF THE URINE. 

The treatment in general is that of acute nephritis. The 
best remedy in the writer's hands has certainly been Tere- 
binth, given in the first decimal to children, the second to in- 
fants and in drop doses to adults. Other remedies recom- 
mended are Crotalus, Phosphorus or Ferrum phos., and Potas- 
sium chlorate. The value of Quinine is disputed. 

Hczmatoporphyriniiria. — The voiding of urine, red when 
passed, and becoming darker on standing, from presence of a 
derivative of haemoglobin called haematoporphyrin. Found 
in excess in poisoning by sulphonal and trional and in the 
urine of typhoid and certain nervous diseases where it is re- 
garded as of bad prognostic significance. 

Hydrothionitria. — The voiding of urine containing sul- 
phuretted hydrogen. Suggests absorption of this substance 
from bowel and hence auto-intoxication ; or else abnormal 
communication between the intestine and urinary tract. 

Indie anuria. — The voiding of urine containing excess of 
indican. Occurs in various intestinal troubles, especially in 
those of the small intestine. The treatment is that of the 
cause. 

Lactosuria. — The voiding of milk-sugar in the urine. Oc- 
curs in pregnancy or after childbirth. 

Lipuria. — The voiding of more than ten grains to the 
gallon of fat in the urine. Usually of importance in con- 
nection with various renal lesions, diabetes, or cancer of the 
pancreas. 

Lipaciduria. — The voiding of fatty acids in the urine. 
Probably of no clinical significance. 

Lithnria. — The voiding of urine containing a brick-dust, 
sediment of urates and uric acid. Already considered. 

Melanuria. — The voiding of urine, black when first passed, 
from presence of a black pigment, melanin ; usually signifi- 
cant of melanotic cancer or sarcoma. 

Melituria. — (See Glycosuria.) 

Mucinuria. — (See Nucleoalbuminuria.) 



ABNORMAL STATES OF THE URINE . 403 

Nucleoalbuminnria. — The voiding of urine rich in the sub- 
stance formerly called mucin. Found in catarrhal affections 
of the urinary tract. 

Oxaluria. — The voiding of urine containing crystals of 
oxalate of lime. (Calcium oxalate.) Already considered. 

Phosphaturia. — The voiding of urine containing a sediment 
of phosphates. 

Peptonuria. — (See Albumosuria.) 

Pyuria. — The voiding of urine containing pus. Found in 
various affections of the urinary tract and considered in con- 
nection with them. 

Uraturia. — (See Lithuria.) 

Urobilimiria. — The voiding of urine containing excess of 
urobilin. Of special importance in cases of concealed haem- 
orrhage, especially in ectopic gestation, indicating absorption 
of extra vasated blood. 

Lcevulosuria. — May occur in cases of over-ingestion of cane 
or fruit sugars or in diabetes. 



CHAPTER XVI. 

DISEASES OF THE BLADDER. 

The commonly recognized conditions are malformations, 
malpositions, dilatation, hypertrophy, atrophy, paralysis, irri- 
tability, circulatory disturbances, amyloid degeneration, in- 
flammations (cystitis), tuberculosis, syphilis, tumors, cysts, 
parasitic diseases and calculus. The bladder may also be the 
seat of wounds or of rupture. 

Malformations. — Absence of the bladder, with opening of 
the ureters elsewhere, as into the urethra or vagina, has al- 
ready been referred to. It usually causes early death. Use 
of a urinal or implantation of the ureters into the rectum is 
the treatment. Diverticula may be present in the form of 
pockets or cells ; a septum may divide the bladder, the condi- 
tion being known as bipartite bladder. There may be multi- 
ple bladders. The treatment is drainage, if cystitis occur 
which does not yield to treatment. 

Patulous urachus may occur as a congenital defect, and cal- 
culi or cysts be present in it. The urine in complete cases 
escapes at the umbilicus. The treatment is surgical. 

The anterior wall of the bladder may be absent in the con- 
dition known as exstrophy. It is usually associated with mal- 
formation of neighboring parts, and is much more common in 
males than in females. As a rule death results in a few days 
after the child is born. Those who live are likely to die from 
urinary septicaemia or exhaustion. In rare cases the patient 
has good health. The treatment consists in the use of a prop- 
erly fitting urinal. In cases where the condition is marked a 
surgical operation is required after the fourth year of life. 

Malpositions. — The most common is vaginal cystocele, de- 
scent of the bladder into the vagina. In women prolapse of 



IRRITABLE BLADDER. 405 

the bladder through the urethra may occur. Hernia may also 
occur, but is rare and generally an inguinal cystocele. 

If the abdominal or pelvic wall is defective, the bladder may 
be externally prolapsed. 

Cystoceles increase and decrease in size according to reten- 
tion or passage of urine. Effort should be made to reduce 
cystocele by means of a truss, otherwise surgical treatment is 
necessary by proper repair of the supports which are lacking. 

Dilatation. — This is due to obstruction to the free flow of 
urine. In acute dilatation we find the bladder-wall thin and 
translucent, but in cases where the obstruction is moderate 
and long-continued the bladder-wall becomes hypertrophied, 
as when due to enlarged prostate. Riesman reports a case in 
which the bladder held 88 fluidounces of urine (2640 c.c). 

Hypertrophy. — This is due to an increased demand for 
contraction and is the usual result of cystitis or other causes of 
obstruction to the free flow of urine. It may also be congenital; 
rarely it is of reflex or nervous origin. Two kinds of hyper- 
trophy are distinguished, concentric where the cavity is not 
larger than normal and excentric when it is larger. In 
marked cases of hypertrophy the bladder has a peculiar ribbed 
appearance in the interior with ridges and depressions ; the 
latter may be filled with concretions or give rise to diverticula. 

Atrophy. — This is usually due to old age or may result from 
prolonged distention. ' 

IRRITABLE BLADDER. 

Definition. — This is a tendency to frequent contraction of 
the bladder with evacuation of urine. If long continued, it 
may lead to hypertrophy. 

Synonyms. — Neuralgia of the neck of the bladder. Fre- 
quent desire to urinate. 

Pathology. — The prostatic sinus being congested and con- 
stantly more or less irritated from irregular or ungratified 



406 DISEASES OF THE BLADDER. 

sexual desire, the congestion extends readily in both directions, 
involving the cut-off muscles in front and creeping back- 
wards into the neck of the bladder through the inner orifice 
of the urethra. The whole urethra is sensitive and irritable, 
but the bladder walls themselves are insensible when touched 
with the point of the sound. The cut-off muscles are excess- 
ively sensitive and irritable. 

Clinical Features. — These are the following: 

Frequent desire to urinate by day and during sleepless 
nights, but little disturbance at night. 

Relief after urination not perfect and desire soon returns. 

In some cases slight burning pain on urination and in severe 
cases tenesmus. 

Either slow small stream or spasmodic urination with great 
force from contraction of the bladder. 

In some cases inability to urinate, or hesitation due to 
spasmodic contraction of the cut-off muscles. 

Etiology. — Due to more or less constant condition of irrita- 
tion of the prostatic sinus in the neighborhood of the seminal 
ducts without inflammator) T lesion. 

The chief cause is irregular or ungratified sexual desire, 
especially in arthritic cases, and where the urine is acid and 
irritating. It may be aggravated by anything capable of in- 
flicting a structural change in the tissues of the neck or its 
neighborhood (stricture, abscess, large prostate, rectal dis- 
eases, stone, worms, inflammations, etc.). 

The disease is more common according to the writer's ex- 
perience in young unmarried men. It may disappear after 
marriage. 

Differential Diagnosis. — Cystitis is differentiated by the 
presence of pus in the urine which is not found in simple ir- 
ritability. The two diseases may co-exist ; in which case the 
extreme sensitiveness of the cut-off muscles will detect the 
cause of the cystitis, as also the history. 

Dr. Peyer considers this affection a neurosis. The chief 



IRRITABLE BLADDER. 407 

symptom, vesical tenesmus, appears both during trie day and 
night ; there is a spasmodic state of the sphincter, with spastic 
enuresis and spastic ischuria, burning on urination, pains in 
the loins, a sense of pressure in the hypogastrium, cold feet, 
anaesthesia or hyperaesthesia of the genitals, inability to stand 
for a time, etc. 

In diagnosis, examine the whole patient, his nervous sys- 
tem, thorax, abdomen, kidneys and pelvic organs, and then 
the bladder. Examine the urine for urethral threads, gonor- 
rhoea, or long-lasting masturbation ; the prepuce for phimosis, 
balanitis, smegma ; the urethra for irritable or inflamed spots ; 
sound the urethra ; examine the post-bulbar portion by the 
rectum. A diagnosis must be made by exclusion. Differen- 
tially, one should exclude : 

i. Acute parenchymatous nephritis, which is recognized by 
albuminuria, casts, blood- and pus-corpuscles. 

2. Contracted kidney presents increased or decreased quan- 
tity of urine, few or no casts, albuminuria and hypertrophy of 
the heart. 

3. Pyelitis has pus and blood in the urine, with pains in the 
regions of the kidneys. 

4. Chronic pyelitis causes the urine to be increased nearly 
double in quantity, so that this sign is almost pathognomonic. 
The albumin is sometimes greater in quantity than the pyuria 
would seemingly give rise to. 

5. Diabetes mellitus and insipidus, as well as retention of 
urine, offer no special difficulties. 

6. A contracted bladder cannot be filled with over 50 to 100 
gms. of urine. 

7. Stone in the bladder has been often operated for without 
any stone having been found. 

8. Fissures of the neck of the bladder are not rarely met 
with in men, and are sometimes due to a former gonorrhoea. 
There is great pain after urination, and in the last drops of 
urine are detected white bodies with red blood-corpuscles. 
The endoscope will confirm the diagnosis. 



408 DISEASES OF THE BLADDER. 

9. A beginning stricture or one of large calibre may be 
gradually accompanied by tenesmus vesicae and a disagreeable 
burning in the urethra. The sound is here the decisive meas- 
ure ; any one that will pass the meatus should pass through 
the whole canal, as the meatus is the narrowest portion. In 
general, where a No. 20 French bougie will not pass, one 
may safely say that there is a stricture. 

The patient can hold his urine better when his mind is oc- 
cupied, or when under stimulation by liquor. 

On rainy, damp or cold days the desire to urinate is greater, 
and also during worry. 

There is depression of spirits, in some cases hypochondri- 
asis. 

Unpleasant sensations may be felt in the rectum or peri- 
naeum. 

Nocturnal emissions are frequently complained of, and ab- 
normalities of erection experienced. 

Spasmodic urethral stricture may occur. 

Functional disturbances of the bowels, often constipation, 
and feeling of lassitude may be present. 

The Urine. — This is usually deficient in acidity, abundant 
in quantity, of light color and somewhat lowered specific 
gravity, without, as a rule, marked deficiency in totals of the 
various solids. Amorphous phosphates and calcium oxalate 
crystals may be found in the sediment. 

Prognosis. — Good, if the disorder is recognized and treated 
carefully. 

Treatment. — The essentials are the following : 

Attention to the sexual element ; purity of thought and 
deed ; out-of-door exercise, gymnastic exercises regularly per- 
formed. 

Avoidance of alcoholic beverages and use of tobacco. 

Change of habits or occupation, rest from business cares. 

In phosphatic cases the treatment of phosphaturia. (See 
Phosphaturia.) 



IRRITABILITY OF THE BLADDER IN WOMEN. 409 

Passage of a moderate-sized steel sound, well-warmed and 
oiled, and introduced with the utmost gentleness : in young 
men every second to fourth day ; in older men, daily. Not to 
be used when there is prostatitis or cystitis. 

Symptomatic Treatment. — Belladonna. — Symptoms given 
under Cystitis. Useful in cases where there is congestion of 
the bladder. Use third decimal. 
. Equisetum. — See Cystitis for indications. 

Ferrum. — In congestive cases with anaemia, and debility. 

Hyoscyamus. — -See Cystitis for indications. 

Nux vomica. — Useful in lithaemic cases. 

Rhus aromatica. — Use the tincture in ten-drop doses or 
more. 

irritability oe the bladder in women. 

Definition. — Hyperesthesia of the trigone without cause 
other than neurosis. In women there is frequently a localized 
hyperemia. (See also below). 

Etiology. — It is due either to neurosis and hysteria or 
malaria ; lithsemia is also a cause. Reflex causes may exist, 
as haemorrhoids, uterine and vaginal diseases. (See also 
below). 

Diagnosis. — Frequent and painful urination without signs 
of inflammation in the urine suggests the condition. 

Clinical Features. — The symptoms are pain and frequency 
of micturition, marked vesical and rectal tenesmus, and dys- 
uria not relieved by micturition. There may also be spasm 
of the bladder and inability to void urine. 

Differential Diagnosis. — Absence of mucus and pus in the 
urine, the clearness of the urine, and the neurotic history dis- 
tinguish the disease from cystitis. 

Prognosis. — Good. The disease is not fatal, but recovery 
may be slow unless some of the surgical measures later de- 
scribed are instituted. 



410 DISEASES OF THE BLADDER. 

Treatment. — Removal of any reflex cause. Moral suasion, 
suggestion, etc., in nervous cases. Observance of regular 
habits. Rest and feeding for neurasthenic patients. Treat- 
ment for lithsemia, if it exist. Use of diluent drinks freely. 
Administration of nerve sedatives and urinary antiseptics. 
(Eichhorst.) 

Cases certainly appear to occur in which no local lesion is 
demonstrable, but the use of the cystoscope in skilled hands 
has of late shown that in the majority of instances the condi- 
tion is not a neurosis, but dependent on some recognizable 
local condition. In 176 cases studied by Bierhoff there was 
in no case a pure neurosis. The abnormal conditions found 
by him were the following : 

Old 

Series New Total. 

Urethritis, — 3 3 

Urethrocystitis (sphincteral inflammation) — 5 5 

Sphincteral papillomata, — 15 15 

Vesical hyperemia, 14 57 71 

Vesical varices, 5 7 12 

Catarrhal cystitis, . . 27 23 50 

Prolapse of anterior vaginal wall (not to the 

extent of cystocele), .... ... — 3 3 

Cystocele, 4 2 6 

Bacteriuria, ... . — 1 1 

Vesical tuberculosis, 1 — 1 

Pericystitis, 27 48 75 

^Carcinoma (extra vesical), 3 — 3 

Pregnancy, 5 9 14 

Malpositions of the uterus, 10 43 53 

Inflammatory conditious of the uterus, or 

adnexa, or both, — 23 23 

Pelvic inflammations, acute (alone or as 

accompanying conditions), — 2 2 

Pelvic inflammations, chronic, — 24 24 

Tumors /Serine, - 

t pelvic, .... — 2 2 

Movable kidney, — 1 1 

Nervous conditions (as accompanying 

causes), -4 5 9 

In cases in which vesical hyperaesthesia exists it does so 



IRRITABILITY OF THE BLADDER IN WOMEN. 411 

only as a symptom ; in the majority of cases as a direct result 
of some change in the vesical mucous membrane, in the minor- 
ity as an indirect result of changes in other organs adjoining 
or near the bladder. 

The diagnosis of the causative factor must rest upon a thor- 
ough examination not only of the bladder, but also of the 
urethra and the genital and pelvic organs as well. 

The treatment must be directed both against the local 
changes and the causative factors of these. 

The principal points in the diagnosis are the following : 

Urethritis. — Examine pus for presence of gonococcus, or 
locate areas of inflammation, fissures, condylomata, etc., by 
use of the. endoscope. 

Urethrocystitis (catarrhal). — In this condition there is usu- 
ally a more marked degree of tenesmus than of pollakiuria. 
The urine is clear and of normal composition. The cysto- 
scope reveals the redness and swelling of a degree of severity 
varying with the intensity of the process. This change is, 
however, one which affects the sphincteral margin exclusively 
or chiefly. The mucous membrane at the sphincter and just 
beyond, on both the vesical and urethral sides, is found con- 
gested and swollen, sometimes markedly so. The surface is 
angry-red and irregular, especially over the lower median por- 
tion. The rest of the bladder is free of inflammation; the 
urethra, however, may also be the seat of a catarrhal inflam- 
matory change. A feature of this condition is the exquisite 
tenesmus it frequently calls forth. 

Hyperemia. — This condition possesses certain points which 
distinguish it from true cystitis, viz., while in cystitis of either 
the suppurative or catarrhal type we see a surface somewhat 
roughened, and of an even, deep-red color, all contours of the 
individual vessels being lost, in hypersemia we can readily 
distinguish that the redness is caused by an abnormality of 
the capillaries, which appear to be increased in number and 
dilated. The individual vessels are, however, still recogniz- 



412 DISEASES OF THE BLADDER. 

able, whilst between them are distinguishable small areas or 
islets of normal, yellowish mucous membrane. Zuckerkandl 
considers local hypersemia a cause of vesical hypersesthesia 
and mentions the increased liability to cystitis resulting there- 
from. Kelly states that he finds it in all those cases hitherto 
diagnosed as "irritable bladder." The condition is due either 
to direct irritation of the mucous membrane, to the extension 
to the bladder of urethral, congestive processes, or it is sec- 
ondary to pelvic congestions, or to pressure of other organs or 
tumor-masses. 

Catarrhal Cystitis. — See also Hyperemia. The inflamma- 
tion is chiefly in the trigone. The surface looks satiny. The 
inflammation may also be present over portions of the bladder 
wall, outside of the trigone, in discrete or confluent patches. 
The urine remains clear or contains only isolated leucocytes, 
epithelium, bacteria, etc. In certain cases the roughening of 
the surface is found to be due to minute papillary growths ; in 
others small transparent blebs or vesicles are found. 

Vesical Tuberculosis. — Bierhoff describes the cystoscopic 
appearances in two cases as follows : Two cases have come 
under observation, one presenting the symptoms of only vesi- 
cal hypersesthesia, the other of a severe, suppurative cystitis. 
Both occurred in females. In the former case, which also 
presented signs of advanced pulmonary tuberculosis, the cys- 
toscope revealed a normal bladder wall, with the exception of 
a large shallow ulceration, with clean-cut edges of somewhat 
irregular outline, on the lower left posterior wall. It rose 
from an apparently normal base, was surrounded by a narrow 
margin of inflammation, and its surface was covered with a 
yellowish-gray coating. The second case also occurred in a 
patient with pulmonary tuberculosis, though not very ad- 
vanced. The history of the acute attack covered only a period 
of six to seven weeks, although there had been slighter trouble 
with urination at intervals over an indefinite period prior to 
this. The cystoscope revealed a diffuse cystitis affecting the 



IRRITABILITY OF THE BLADDER IN WOMEN. 413 

trigone. At different points over the bladder-wall were dis- 
tinct ecchymoses, surrounded by apparently healthy walls. 
Both ureteral orifices (notably the right) were swollen and in- 
flamed. On the upper left lateral wall were three small su- 
perficial ulcerations, discrete, with clean-cut edges, rising from 
an apparently healthy mucous membrane, and surrounded by 
a narrow zone of inflammation. They were covered with a 
yellowish-gray coating. Catheterization of the ureters re- 
vealed a considerable quantity of pus in the urine from the 
right kidney, a small amount in that from the left. 

The first case he regards as primary, the second secondary, 
to renal tuberculosis. 

Pregnancy. — This may cause vesical hyperesthesia, either 
as a direct result of pressure upon the bladder by the distended 
uterus, or as a result of the vesical hyperemia, varices, etc., 
which it may bring about through interference with the pel- 
vic circulation (Peyer, Fritsch, Zuckerkandl, Viertel, Casper). 
These conditions may occur in the earlier months of preg- 
nancy and become more pronounced if the distensibility of 
the bladder is interfered with by pericystitic strands, or adhe- 
sions. The cystoscope reveals a rounded tumor, covered with 
normal mucous membrane, protruding into the bladder. Close 
inspection shows it to be marked with rounded long irregu- 
larities, in all probability the fiber bundles of the uterine 
muscle seen through the bladder-wall. Another condition 
seen at times during pregnancy is a decided prominence (both 
in depth of coloration and in extent of development) of the 
venous plexuses of the vesical wall. These may, at times, es- 
pecially if there is cardiac insufficiency, become pronouncedly 
varicose. 

The prognosis of vesical hyperesthesia is good. It is not, 
of itself, a serious condition, but may prove a very favorable 
foundation for graver conditions of the urinary organs. The 
cases due to local inflammatory changes are most readily and 
quickly cured. In the presence of extravesical causes, how- 



414 DISEASES OF THE BLADDER. 

ever, the course of the disease is slower and more tedious, and 
may extend over months, or v even years ; if neglected , it may 
lead on to incurable exstrophy of the bladder. 

His methods of treatment are as follows ; 

Urethritis. — Treat the cause, as e. g., gonorrhoea, fissures, 
condylomata, areas of inflammation, etc. 

Urethrocystitis. — Application of Nitrate of Silver, 0.5 per 
cent, to 2 per cent. 

Papillomata. — Cautery, strong caustics, or the snare. 

Hyperemia. — Removal of extravesical pressure-causes ; 
subsequently irrigations of one per cent. Boric Acid alone or 
followed by instillations of 0.25 to 0.50 per cent. Silver 
Nitrate. 

Varices. — Removal of any obstruction to the venous circu- 
lation; bladder washing with a large catheter, if there are 
haemorrhages ; as a hemostatic, solutions of Antipyrin or 
Ferripyrin ; severe bleeding may require actual cautery. 

Catarrhal Cystitis. — Vesical irrigations with one per cent. 
Boric Acid, followed by instillation or injection of 0.25 per 
cent to 2 per cent. Silver Nitrate, with Urotropin internally. 

Cystocele. — Gynaecologic treatment. 

Bacteriuria. — In bacteriuria the urine is turbid, and upon 
examination the turbidity is found to be due entirely to bac- 
teria. Bacterium coli is most frequently the germ found in 
this condition. The internal use of Urotropin alone, as de- 
scribed before, or alternated with Salol, in conjunction with 
the regulation of the bowels, and with bladder-irrigation with 
one per cent. Boric Acid solution, followed by one-tenth per 
cent, to one-fourth per cent. Nitrate of Silver solution, usually 
gives the best and speediest results. 

Vesical Tuberculosis. — Treatment should, first of all, be di- 
rected to the general condition. Local treatment consists of 
measures varying from injections of Nitrate of Silver solution 
to Iodoform emulsion, to curettage, cauterization or excision. 

Pericystitis. — Treatment consists of a gradual stretching of 



IRRITABILITY OF THE BLADDER IX WOMEN. 415 

the perivesical strands, by means of a gradual, progressive dis- 
tention of the bladder with fluid. Tepid Boric Acid solution 
is slowly and gently injected to the point of tolerance, and 
allowed to remain a few minutes. The procedure is repeated 
at daily intervals, if possible, the quantity of fluid being grad- 
ually increased. 

Carcino?na. — Simple irrigations at times afford relief. 

Pregnancy. — If no inflammatory reaction is present, no 
treatment is needed. When it is present, however, benefit is 
obtained from irrigations, followed by the application of 
Nitrate of Silver solution, of one-tenth per cent, to one-half 
per cent., through the endoscopic tube to the trigone and 
sphincter. In cases in which there is a tendency to abort, ir- 
rigations alone should be employed. 

Malpositions of the Uterus. — Treatment gynsecologic. 

Inflammatory Conditions of the Uterus, or Adnexa, or 
Both. — These may exert an influence through the extension 
of inflammation to the bladder by bringing about congestion 
affecting this viscus, or by limiting its distensibility. 
Treatment of the bladder is unnecessary ; it should be di- 
rected toward the original condition, since the vesical hy- 
peresthesia usually disappears with the subsidence of the in- 
flammation. 

Pelvic Inflammations {acute). — These act similarly to the 
preceding. 

Pelvic Inflammations {chronic). — These act, as does peri- 
cystitis, chiefly mechanically, through limiting the distensi- 
bility of the bladder. 

Tumors {pelvic and uterine). — These become factors in the 
causation of vesical hyperesthesia, either because of their 
direct pressure upon the bladder or by bringing about conges- 
tion of the vesical mucous membrane through interference 
with the pelvic circulation. They are only recognizable with 
the cystoscope when they press directly upon the bladder. 
Then they present a protrusion, of rounded contour, into the 
vesical cavity. 



416 DISEASES OF THE BLADDER. 

Movable Kidney. — The extent to which a movable kidney 
may act as a factor in the production of pollakiuria has not 
been decided. 

Nervous Conditions. — The nervous conditions we have met 
have been neurasthenia, hysteria, ataxia and epilepsy. Of 
these neurasthenia occurs most frequently and is of the great- 
est importance as a contributory cause. It stands to reason 
that, if the nervous system is weakened, conditions which 
otherwise would perhaps pass unnoticed may produce marked 
symptoms. Then, again, allowance must also be made for 
the natural tendency to exaggerate symptoms or conditions 
which is present in those suffering from nervous conditions. 
Coincident with the treatment of whatever vesical or ex- 
travesical changes may be present must be that of the nervous 
disease. 

PARALYSIS OF THE BLADDER. 

Synonym . — Cystoplegia. 

Definition. — Loss of power of contraction. 

In cases of paralysis the bladder loses its power of contrac- 
tion, becomes distended with retained urine, and incontinence 
of urine results. 

Etiology. — The causes are lesions of the spinal cord, over- 
distention or prolonged compression. A frequent cause of 
the latter is the pregnant uterus. 

Inflammations of the bladder, carcinoma, and nervous, hys- 
terical or hypochondriacal conditions are common clinical 
causes. Debility from masturbation and senile marasmus 
are also causes. 

Diseases of the spinal cord in which it occurs are com- 
monly the following : Myelitis, tabes, multiple sclerosis and 
spinal concussion. It is sometimes noticed in cases of soften- 
ing of the brain and in opium poisoning. 

It may occur after excessive distention from any cause, as 



MOfOR NEUROSES. 417 

in cases of alcoholic intoxication, and is common in the case 
of persons who on account of occupation are obliged to re- 
tain their urine for long periods of time. It may be due to 
stricture or prostatic hypertrophy. 

Diagnosis. — Inability to void urine without pain and the 
presence of residual urine suggest this disorder. 

Clinical Features. — Two kinds of paralysis are observed, 
that of the detrusor and that of the sphincter, or simultane- 
ous paralysis of both. 

In paralysis of the detrusor we find difficulty in voiding 
urine and great straining ; in paralysis of the sphincter drib- 
bling and incontinence of urine. 

A combination of the above symptoms occur when both 
sphincter and detrusor are paralyzed. 

MOTOR NEUROSES. 

The motor neuroses of the urinary system are either 
spasmodic contractions or paralysis. Dribbling of urine after 
micturition is probably due to spasmodic contraction of the 
organic muscular fibres of the urethra throughout its whole 
length. Spasm of the external sphincter shows itself by 
more or less inability on part of the patient to urinate, though 
the impulse is frequent. The treatment is the daily passing of 
large metallic sounds, allowed to remain in from five to fifteen 
minutes. 

Spasm of detrusors (cystospasmus) is shown by a frequent, 
though generally painless, impulse to urinate, for the most 
part only by day, but also during any sleepless nights. The 
urine is clear, pale, of low specific gravity, neutral or faintly 
acid, or even alkaline, and increased in quantity. The phos- 
phates appear on heating. If the disorder is the result of 
gonorrhoea, we find short, thick shreds from the prostatic 
urethra. The treatment is to decrease mental work, prohibit 
sexual excesses, advise change of air, travel, sea bathing, 
27 



418 DISEASES OF THE BLADDER. 

agreeable recreation, etc. Internally, China, Ferritin, Ar- 
senicum, in the lower pecimals. In severe tenesmus, Mor- 
phine suppositories. If due to gonorrhoea, sexual excess or 
masturbation, then passage of sounds, use of short urethral 
catheter, warm rectal injections and warm baths. 

Paralysis of the bladder is shown by inability to empty the 
bladder completely. The diagnosis is made by passing 
catheter immediately after patient has urinated. The amount 
of urine then drawn off is a measure of the insufficiency of 
the bladder. Moreover, patients complain that they have to 
wait long before urinating, pressing and straining ; when the 
urine comes, it falls feebly down. There is no feeling of satis- 
faction after urinating. If the paresis pass gradually into 
paralysis incontinence occurs, first at night, but later becomes 
constant. The diagnosis between paresis of the sphincter 
and of the detrusor is made, according to Ultzmann, as fol- 
lows : 

Paralysis of the Sphincter. Paralysis of the Detrusor. 

Incontinence of urine, early and in Incontinence late and in the night 

the day first. first. 

No retention. Retention possible. 

No distention. Bladder distended. 

No dulness over symphysis. Several finger-breadths of dulness 

over symphysis. 
No resistance to catheter. Powerful resistance. 

i 

The Urine. — In paralysis of the bladder the urine may be 
normal or neutral, or feebly alkaline, with a sediment of 
earthy phosphates. Diabetes decipiens is sometimes an ac- 
companiment. Gradually a purulent bladder catarrh comes 
about. 

The treatment of paralysis is as follows : In light cases 
when in strong persons slow and infrequent micturition is es- 
tablished, daily massage of the bladder, regular micturition 
at short intervals and with use of mineral waters containing 
salts of soda, as Carlsbad ; regular exercise with cold rubbing 



SPASM OF THE BLADDER. 419 

of entire body, cold sitz-baths, douching of the perinaeum 
and over the bladder and lumbar region, cold showers on the 
back immediately after coming out of a hot bath. [In- 
ternally, Ultzmann advised Quinine, Ergot, Strychnine. 
The latter hypodermically, T f q of a gramme of Strychnine 
nitrate in 10 c.c. of distilled water, one-half to a whole 
Pravaz syringeful daily, injected into the skin of the abdo- 
men over the bladder ; to be discontinued if muscular twitch- 
ing, etc., appear.] 

A thoroughly carried out regular course of catheterization 
with vulcanized rubber catheters is advised by Ultzmann. 
After some weeks or months of catheterization electricity 
may be used, one pole as a catheter-formed electrode being 
passed into the bladder, and the other placed over the lumbar 
vertebrae, or introduced into the rectum. Electricity should 
not be used too early nor at all if there is purulent pyelitis 
or nephritis. 

In paresis of the sphincter, or when this predominates, the 
electrode need be passed only into the prostatic urethra. 

For dribbling of the urine faradic applications every day or 
every other day. Let the patient sit on a wet sponge con- 
nected with one pole of the battery and place the other over 
the pubes. Use a pleasant current and reverse several times 
during the treatment. Also apply the negative to the spine, 
especially the lumbar region, positive at the base of the spine. 
Treatments may last from fifteen to twenty minutes. 

SPASM OF THE BLADDER. 

Synonym. — Cystospasm. 

Etiology. — It may be due to various diseases of the bladder 
or be purely of nervous origin in hysterical, hypochondriacal 
or neurotic patients ; it is also observed in masturbators. In 
rare cases it is reflex from diseases of the uterus or ovaries, or 
may be due to worms. It may follow the drinking of young 
wine or beer, or the eating of asparagus. (Eichhorst.) 



420 DISEASES OF THE BLADDER. 

Clinical Features. — Two kinds of spasm are noticed, spasm 
of the detrusor and of the sphincter. The former is charac- 
terized by a periodically-occurring abnormal desire to urinate, 
even if the amount of urine be small. The latter evidences 
itself either by the passage of urine drop by drop or complete 
retention, together with intense pain in urinating, which may 
radiate to the anus, testicles and glans penis. 

The spasm may simultaneously involve both detrusor and 
sphincter, in which case we find an abnormal desire to urin- 
ate, with obstruction to the flow and pain on voiding urine. 
The patient is pale, faint and bathed in perspiration. 

Differential Diagnosis. — The disorder is distinguished from 
cystitis by the absence of changes in the urine. 

Treatment. — This consists in hot applications to the blad- 
der and the use of warm baths (99. 5 F.). The patient should 
be advised to try to urinate while in the warm bath. For the 
pain morphine suppositories in the rectum may be used. 

Retention of urine in paralysis or spasm calls for hot baths, 
copious rectal enemas, and symptomatic treatment with such 
remedies as Gelsemium, Ignatia, Moschus, Hyoscyamus, Zin- 
cum, Pulsatilla, Caulophyllum, Asafoetida. Irrigation of the 
urethra with warm Boric acid solution, and a rectal supposi- 
tory of Opium, one-half grain, and Belladonna, one-quarter, 
are advised by Carleton, If these fail the catheter must be 
used. 

Circulatory Disturbances. — These are (1) active and passive 
hypersemia and (2) haemorrhage. 

Active hyperemia is due to the presence of irritant sub- 
stances in the urine, but is usually not recognizable until after 
death. It is occasionally seen in the bladder of women who 
have died from septic infection. 

Passive hyperemia is the result of pressure on the vena 
cava, as by tumors or the pregnant uterus, and in time may 
lead to varicosis of the bladder and haemorrhage. 

Hcemorrhages are most commonly due to calculus or 



CYSTITIS. 421 

tumors. Bladder tumors, even though small, may bleed pro- 
fusely, causing profound anaemia and death. Haemorrhages 
may also be due to inflammation, passive congestion, vari- 
cosis, trauma and the haemorrhagic diathesis. 

In cases of hyperaemia of the bladder local applications of 
Nitrate of Silver and of Glycerite of Tannin and Ichthyol ; 
the fine coil of the Faradic current ; absolute rest and mild 
diet ; correction of any abnormal condition of the urine ; per- 
fect drainage and rest for the bladder by means of an artificial 
vesico-vaginal fistula are now advised. 

Vesical hemorrhoids may be recognized by the cystoscope. 
Haemorrhage from no obvious cause may be due to them. A 
few fatal cases have been chronicled. The treatment consists 
in giving Hamamelis, tincture, internally in one-drachm doses 
three times daily, together with irrigation of one per cent. 
Tannic acid solution and one-half per cent. Alum solution, 
alternated with a three per cent. Boric acid solution or a one 
per cent. Salicylic acid solution. 

Retention of urine from obstruction of the urethra by blood 
clots is usually overcome by waiting until the urine becomes 
ammoniacal and dissolves the clots. If this is impossible 
catheterization or supra-pubic cystotomy is necessary. If the 
catheter cannot be introduced, aspiration of the bladder may 
be successfully used if with aseptic precautions. 

Amyloid degeneration. — This is rare and usually a part of 
general amyloid disease ; occasionally it may result from 
chronic inflammation. 

CYSTITIS. 

Synonym. — Inflammation of the bladder. 

Definition. — Inflammation of the mucous membrane of the 
bladder. 

Note. — In order to understand much that follows, reference 
should be made from time to time to Figures 26, 29, 32, 33, 



422 DISEASES OF THE BLADDER. 

34, 36 and 3J, in which the anatomy of the parts is brought 
out. 

Etiology. — The disease is due to bacteria, but, as is fre- 
quently the case in bacterial diseases, there are a number of 
factors which favor the action of micro-organisms ; these are 
retention of urine and all conditions favoring stasis, injury, 
stone, exposure to cold, irritant qualities of the urine, and 
lesions of the spinal cord. 

Commonly cystitis is due to the Bacillus coli communis, 
which, however, is incapable of producing cystitis in the ab- 
sence of the predisposing factors. 

The Proteus vulgaris, by virtue of its ability to cause 
decomposition of the urine, may cause cystitis. It is possi- 
ble that the gonococcus, the typhoid bacillus, and the thrush- 
fungus may also produce it. Slight degrees of cystitis are 
found in infectious diseases, especially typhoid fever, influenza, 
mumps, scarlet fever, and others in which a slight degree of 
acute nephritis exists. Probably due to local action of 
bacteria or toxines concerned in the origin or progress of the 
primary disorder. Cystitis is frequently associated with gout, 
and is explained as a result of a direct irritation of the mucous 
membrane by the concentrated urine. 

It ma) 7 be due to injuries from instruments, injections, 
pressure of faeces or of pessaries, or the foetal head ; foreign 
bodies, as calculi and bacteria, especially the gonococcus ; ir- 
ritating substances taken internally may produce cystitis, as 
Cantharides, Copaiba, Cubebs, or even Mustard ; retention of 
urine from whatever causes ; extension of inflammation from 
neighboring parts, especially when an unclean catheter is 
used. 

It is associated with flexions of the uterus, constipation, 
and may occur after suppression of urine. 

It may be due to masturbation, excessive venery and 
haemorrhoids. 

Clinically we find cystitis most common following gonor- 



CYSTITIS. 



423 



rhcea in young men, the result of stone or enlarged prostate 
and retention of urine in old men, and in women as a result 
of childbirth or extension of inflammation from the vagina or 
rectum. In diseases of the spinal cord cystitis from retention 
is common. 

In other words, cystitis is essentially a secondary disorder. 




Fig. 26.— Relations of the posterior and inferior regions of the bladder in man. 1, 
right half of posterior surface of bladder; 2, left half covered with peritonaeum; 3, semi- 
circular fold which this membrane forms when empt}'; 4, median section of this fold; 6, 
right seminal vesicle; 8, seminal duct; 9, ureter; 11. 11, left ureter, covered with perito- 
naeum; 12, spermatic vein and artery; 15, external iliac artery and vein. — (Sappey.) 

Pathologic Anatomy. — Cystitis may be either catarrhal, 
phlegmonous or interstitial, diphtheritic or pseudo-membran- 
ous, and gangrenous. 

Catarrhal cystitis may be either acute or chronic. Acute 
catarrhal cystitis is marked by red, swollen mucous mem- 
brane, and slimy bladder contents ; purulent contents mark a 
suppurative condition. 

In severe cases haemorrhages and superficial ulceration may 
occur. The trigone, and urethral and ureteral orifices are the 
favorite seats for the changes. 



424 DISEASES OF THE BLADDER. 

The bladder is usually empty and contracted after death, 
and in some cases there is little alteration of the mucous 
membrane other than more or less oedema. 

Chronic catarrhal cystitis is marked by blue slate-colored 
spots in the mucous membrane, and slimy rather than puru- 
lent contents. 

There is usually hypertrophy of the bladder-wall, especially 
involving the muscular coat, and the interior of the organ has 
a ribbed or trabeculated appearance. The veins are promi- 
nent, and the mucous membrane has a yellowish appearance 
and is covered by shreds of mucus and urinary salts, espe- 
cially in the depressions between the trabecular If the cys- 
titis is due to spinal disease with paralysis, the bladder- wall 
may be thin and stretched. 

Pseudo-membranous cystitis is marked by the presence either 
of fibrinous clots, or more frequently by ecchymoses, ulcera- 
tions and superficial necrosis, the latter appearing as opaque- 
gray or yellow 7 patches, sometimes containing urinary salts, 
which are especially prominent at the neck and on projecting 
folds of the mucous membrane. 

The condition is at times found in women after labor, but 
more commonly occurs in cases where there is advanced am- 
moniacal decomposition of the urine, especially in connection 
with nervous paralysis of the bladder. In severe cases there 
is an extensive exfoliation of the mucous membrane. 

Phlegmonous cystitis is characterized by destruction of the 
submucous layer and detachment in shreds or flakes of the 
mucous membrane, or exfoliation of the same as a cast. 

It occurs in chronic cystitis, especially when due to reten- 
tion of urine from stricture or from enlarged prostate ; the 
submucous layer may become, in the course of these diseases, 
the seat of a purulent infiltration, causing a bulging into the 
bladder with eventually perforation. If the latter is internal 
an ulcer develops ; if external, diffuse cellulitis (para-cystitis), 
is produced. 



CYSTITIS. 



425 



Gangrenous cystitis occurs most commonly in the cystitis 
accompanying paralysis of the bladder ; it is also found in 
acute septic conditions, severe injuries, and malignant tumors. 
The favorite seat of the process is the trigone, which is 
covered by a greenish slough surrounded by an intensely in- 
jected mucous membrane. Perforation occurs in this form of 
cystitis. 




Fig. 27. — rower part of the male bladder, with the beginning of the urethra. Exposed 
by incising the anterior wall and laying it open. 3, ureter; 4, opening of the ureter; 
2, vas deferens ; 9, colliculus seminalis; 7, Bell's muscle ; 8, section of prostate ; 10, ori- 
fice of the common ejaculatory duct ; 11, opening of utricle ; 12, mouths of prostatic gland- 
ducts ; 1, Mercier's band. — (Henle.) 

In addition to the above forms we find variolous cystitis in 
small-pox, characterized by a specific eruption on the 
mucous membrane of the bladder and possibly also a true 
diphtheria of the bladder. A rare form of cystitis known 
as cystitis granularis is known, characterized by the presence 
of small nodules in the mucous membrane, especially in the 
region of the neck. The nodules are composed of highly 
vascular lymphoid tissue. 



426 DISEASES OE THE BLADDER. 

Cystitis due to presence of cysts is also known to occur. 

Diagnosis. — Cloudy urine voided with frequency and pain 
suggests cystitis. 

Clinical Features. — In acute cystitis we notice the follow- 
ing features : 

Pain in the bladder. 

Tenesmus. 

The condition of the urine. 

The pain and tenesmus are probably referable to inflamma- 
tion in the neck of the bladder and, in women, to inflamma- 
tion of the urethra accompanying the disorder. 

The tenesmus is even more severe and distressing than the 
pain, and may amount to strangury, with micturition every 
few minutes and passage of blood at the close of it. 

The pain is usually referred to the region of the symphysis 
pubis, but may extend to the perinseum and rectum ; is early, 
distressing and persistent. May be preceded by a chill and 
fever, the latter lasting for some little time. There may be a 
sense of weight and an aching feeling in the perinaeum, which 
is increased by accumulation of faeces in the rectum. The 
pain is somewhat relieved by micturition. There is usually a 
heavy or markedly painful feeling in the hypogastric region, 
which is greatly increased by pressure. 

In chronic cystitis pain and tenesmus is not so noticeable, 
but the obstruction to the flow of urine and constant fermen- 
tation of urine result in frequent and difficult urinations, ex- 
tending over a period of weeks or months, with backache, 
headache, leg-ache, and a whole line of symptoms more or less 
distressing, including constipation, alternating with diarrhoea. 

Chronic cases are serious where paralysis of the sphincter of 
the bladder occurs. Owing to involuntary micturition the 
patient's clothing becomes saturated with urine and the odor 
is noticeable to one entering the room where the patient is. 
In eccentric hypertrophy the bladder can be felt above the 
pubes and is never empty. In concentric hypertrophy it is 



CYSTITIS. 427 

felt as a hard globular body by the finger in the rectum or 
vagina. 

The Urine. — The feature is the cloudiness of the freshly- 
voided urine, due to particles of slime, leucocytes, epithelia, 
numerous micro-organisms and some few blood-corpuscles. 
The color in acute cases is darker than normal, the quantity 
not being increased, but rather diminished. In chronic cases 
the color is often lighter than normal. The reaction in acute 
cases is acid, in chronic cases usually alkaline. In some few 
cases of long-standing cystitis in old men with enlarged pros- 
tate the urine remains persistently acid. 

It is a mistake to think that the urine must be alkaline in 
cystitis ; in some cases of mucous cystitis the reaction may 
even be hyper-acid. 

The sediment contains numerous polynuclear leucocytes, 
large, round epithelia from the middle layers of the bladder, 
occasional blood-corpuscles, and numerous micro-organisms in 
the acute cases. In chronic cases with alkaline urine we find 
the usual phosphatic sediment and ammonium-urate crystals. 
(See writer's Urinary Analysis, pages 262, 274, 278.) The 
micro-organisms in chronic cystitis are usually pathogenic 
bacteria. (Urinary Analysis, page 323.) 

The pus in chronic cases is sticky, in acute cases flocculent. 
The pus-corpuscles in chronic cases are partially destroyed by 
the alkaline urine, so that much granular debris is found, and 
those corpuscles which remain may be ill-defined and indis- 
tinctly seen. 

Heitzmann located the seat of the inflammation by observa- 
tion of the size of the epithelia from the middle layers, the 
large ones coming from the region of the neck. 

The urinary solids are usually somewhat diminished in 
total amount. 

Albumin is present in considerable amounts in acute post- 
gonorrhoeal cystitis involving only the vesical neck — some- 
times enough to settle to mark 1 on the Esbach tube. Such 



428 DISEASES OF THE BLADDER. 

quantity of albumin makes showing enough, when the urine 
is boiled, to alarm both physician and patient. In other 
cases but a trace of albumin is found, especially in chronic 
cystitis. Nucleo-albumin (mucin) reaction is prominent in 
these cases. 

The odor is strongly acrid in the acute cases, but not am- 
moniacal when freshly voided. On standing, however, the 
ammonia odor is soon perceived. 

In chronic cases an acrid odor is also common, but in the 
more severe cases an ammoniacal odor is noticed. In the 
ulcerative cases a particularly foul odor is present. 

There may be a fcecal odor in purulent cases due to pene- 
tration of the bladder by gas from the bowels ; an odor of 
sulphuretted hydrogen may also be noticed (hydrothionuria), 
and in diabetic cystitis gas may be passed from the bladder 
(pneumaturia). 

In chronic cases the urine becomes more and more cloudy, 
although perhaps lighter colored ; the pus increases, and 
sometimes also the albumin. The pus becomes sticky, owing 
to the alkalinity of the urine. 

The amount of albumin is variable and, while it seems, as 
a rule, to bear relation to the amount of pus present, some- 
times we find but a trace of albumin where there is much pus 
and at other times more albumin than the small bulk of pus 
would appear to account for. 

The writer finds that a sediment of pus-corpuscles which 
measures iyi per cent., when sedimented for five minutes at 
a speed of iooo revolutions, may be found in urine which 
yields no measurable quantity of albumin with the ferrocyanic 
test-liquid. 

If, on boiling the urine, a moderate precipitate of albumin, 
one-twentieth to one-twenty-fifth of the volume of the urine, 
is formed, its exclusive origin from pus is to be inferred, if 
several pus-corpuscles are found by the microscope in each 
drop of the shaken urine. 



CYSTITIS. 429 

Differential Diagnosis. — Cystitis may be differentiated 
from pyelitis by the vesical pain, tenesmus, and the character 
of the urine. Presence of casts, together with a larger 
amount of albumin than pus or a small quantity of blood will 
account for, suggests renal complication. 

Differential Diagnosis in Pyuria. — In doubtful cases there 
are several methods which may be of service. The writer 
has found that washing out the bladder before the urine for 
examination is voided often makes it possible to find tube 
casts, which, when much pus is present, may escape notice. 

Thompson's method of deciding whether pus comes from 
the kidneys or bladder is the following : 

Take a clean, soft rubber catheter, a piece of three- 
sixteenths-inch rubber tubing, a two and one-half inch 
glass funnel and a two-inch piece of glass tubing. 
Into one end of the rubber tubing insert the stem of 
the funnel, and in the other end the glass tubing. The glass 
tubing must be drawn down small enough to insert in the 
distal end of the catheter. Now pass the catheter into the 
bladder (noting the point at which the passing is painful), 
and draw off the urine. Insert the glass tubing into the end 
of the catheter. Raise the funnel to sufficient height so that 
there is force enough for liquid to run freely into the bladder. 
Pour in very carefully a warm solution of Boracic acid, then 
lower the funnel, and let it act as a siphon to draw the solu- 
tion out again. Repeat this until the washings are clean. If 
more than two ounces can be borne without much distress, 
there is no objection to using three or four ounces at a wash- 
ing. Now let the apparatus remain in situ for ten or fifteen 
minutes (raising the funnel), then draw off the urine which 
has descended from the kidneys, and set it aside for examina- 
tion. Now repeat the process of washing. If the first wash- 
ing is fairly clean, it is reasonable to say that the pus comes 
from the kidneys or ureters. If, however, a single washing 
does not cleanse the bladder, it is reasonable to say that the 
pus is from the bladder. 



430 DISEASES OF THE BLADDER. 

Ureteral catheterization will not only decide whether the 
pus is from the kidneys or bladder, but, if from the kidneys, 
whether from one or both. The instrument known as the 
segregator, originally devised by Harris, of Chicago, is also 
useful for this purpose. 

Course and Effects. — In acute cystitis, if a mild form is 
present, the fever subsides in a few days, the pain and tenes- 
mus gradually disappear, and the urine becomes normal in 
from eight to ten days. 

Severe forms of acute cystitis show greater febrile disturb- 
ance, more irregular course, and frequent wide daily varia- 
tions between the extremes. The severity of the symptoms 
may be due to complicating pyelonephritis. Cerebral symp- 
toms (delirium, somnolence, stupor) may appear. 

Abscess may form, symptoms of which are localized in- 
duration, pain, and tenderness shown by rectal examination. 
If the severe symptoms continue the patient may collapse, 
temperature become sub-normal and pulse imperceptible. 

Prevesical inflammation in the space defined by Retzius 
may be in part a result of cystitis, and is shown by a sharply 
defined, usually symmetrical tumor above the symphysis, 
terminating in suppuration, though sometimes undergoing 
resolution. 

In abscess formation sloughs of mucous membrane may 
plug the urethra. 

The severer forms of acute cystitis or acute exacerbations 
of chronic cystitis represents usually (a) diphtheritic or gan- 
grenous inflammation of the mucous membrane, or (d) exten- 
sion of the inflammation to the subperitoneal and paracystic 
fibrous tissue. 

In chronic cystitis pain and tenesmus may be comparatively 
slight, but the urine grows more and more cloudy, the sedi- 
ment contains more pus, while albumin increases. The pus 
becomes sticky from the action of the alkaline urine and 
forms a gelatinous mass, which can be removed from the 



TREATMENT OF CYSTITIS. 431 

vessel only with difficulty. The digestion becomes more or 
less impaired, and there is slight loss of flesh and strength. 

In time cystitis leads to hypertrophy of the bladder-wall, 
unless the viscus is permanently distended. The infection 
frequently ascends, as has already been described, causing 
pyelitis and pyelonephritis, occasionally ureteritis ; or it may 
extend to surrounding tissues, causing pericystitis if the peri- 
tonaeum is affected, or paracystitis if the connective tissue 
about the bladder. 

Ulceration may occur in the course of severe cystitis ; also 
in other conditions, as calculus, tuberculosis, and injury from 
pressure by the child's head during labor, resulting in vesico- 
vaginal fistula. 

Cholesteatoma may occur, especially in calculous cystitis. 

Prognosis. — Depends on the length of continuance of the 
disorder. In long-continued chronic cystitis the prognosis is 
undoubtedly unfavorable from danger of extension to the 
kidney or to the neighboring fibrous tissue. When abscesses 
form there is danger of peritonitis from extension toward the 
peritonaeum. If the abscess evacuates into the bladder, there 
is relief to the pain and discomfort. 

TREATMENT OF CYSTITIS. 

Prophylaxis. — The essentials of prophylaxis are the fol- 
lowing : 

i. The patient should avoid exposure of the abdomen 
when the body is heated. 

2. Instruments, as catheters, to be passed into the bladder 
should be thoroughly sterilized. 

3. Urethritis, if it occurs, should be thoroughly treated. 

4. Caution should be observed in the internal administra- 
tion of cantharides, balsams and other irritants. (Bichhorst.) 

Hygiene and Various Palliative Measures. — In acute 
cystitis rest in bed, with elevation of the pelvis, is helpful. 
Administration of teas made of hops or linseed is advised. 



432 DISEASES OF THE BLADDER. 

Hot applications (as an ear of corn which has been 
boiled) to the perinaeum, warm sitz-baths, fomentations of hot 
water, and hot water enemata sometimes do good. 

Warmth of clothing and of climate are essential, the latter 
especially in chronic cystitis. 

Constipation should be overcome by massage of the colon, 
oatmeal at breakfast, hot water enemata, or Rubinat water. 

In very severe asthenic cases leeching the perinaeum will 
relieve the pain there. 

In chronic cystitis the patient should wear an abdominal 
bandage, should take warm baths (99 ° F.) for fifteen to thirty 
minutes, twice to four times weekly, put on warmed clothing 
after the bath, and rest or sleep in a bed with warmed bed- 
clothing. 

Diet. — In acute cystitis the patient is to avoid salty and 
spiced foods, asparagus, pork, lobster, cheese, beans, fried 
foods, pastry and acid fruits ; also beers, champagne, coffee, 
all acid drinks, and saline mineral waters. May drink lithia 
waters freely during the day, but in small quantities at a time. 
A small cup of hot milk at bedtime is useful. 

If the symptoms are severe, absolute milk diet should be 
insisted on. 

In chronic cystitis the diet should be nutritious and readily 
digestible, owing to the tendency to gastric derangement. In 
acute exacerbations the diet should be as in acute cystitis. 

One of the writer's patients with chronic cystitis in locomo- 
tor ataxia seemed greatly helped by buttermilk and Stafford 
mineral water. 

Mineral Waters. — A large number of mineral waters are 
recommended in cystitis. Those which are slightly laxative 
and diuretic seem to suit the patients best, as French Vichy, 
Geneva Lithia, and Allouez. French Vichy is particularly 
serviceable in cases in which pus is found in the urine associ- 
ated with uric acid crystals. A glass may be taken one hour 
before each meal. 



TREATMENT OF CYSTITIS. 433 

Medical Treatment. — In general the measures should be 
the following : 

1. Rest in bed with hips elevated. 

2. Use of urinary diluents and demulcents. 

3. Anodynes for rectum. 

4. Urinary antiseptics internally. 

5. Hot hip baths and hot applications. 

6. Hot rectal enemata. 

The urinary diluents and demulcents which are often of 
greatest service are fluid extracts of Buchu or Triticum and 
infusion of flaxseed. Boiled milk with lime water, one table- 
spoonful of the latter to a glass of milk; weak tea and French 
Vichy water are also serviceable. 

For anodyne a rectal suppository containing one-fourth to 
one-half a grain of Morphine sulphate with one-half to two 
grains extract of Belladonna is useful. 

Symptomatic Treatment. — The following remedies with 
their indications have been advised in cystitis : 

Apis mel. — Great irritability of the bladder ; frequent urg- 
ing, with burning and smarting in the urethra ; urine dark, 
scanty, bloody ; thirst absent ; after abuse of Cantharides and 
other irritating drugs. (Use third decimal.) 

Arnica. — Traumatic inflammation ; urine scanty, with thick 
brown sediment ; after passage of calculus from the kidney. 

Arsenicum alb. — Burning pains on beginning to urinate ; 
bladder distended without desire to urinate ; retention of urine, 
and the usual constitutional symptoms. 

Aconite. — Urinary symptoms, with great anxiety, restless- 
ness, dry, hot skin and hard, quick, full pulse. (The first 
decimal.) 

Belladonna. — Useful in acute cystitis, with highly sensitive 
bladder, urethral spasm and dysuria. (The second decimal.) 

Berberis vulg. — Violent pain, stretching, burning and tear- 
ing from kidney to bladder ; cutting, constrictive pain in 
bladder ; desire to urinate, with burning in the urethra before 
28 



434 DISEASES OF THE BLADDER. 

and after; all urinary troubles worse on motion, and generally 
accompanied by pain in the loins and back ; to be thought of 
in ureteritis ; bran-like sediment in the urine. (Use tincture.) 

Benzoic acid. — Irritable bladder, with pain when not urinat- 
ing ; dribbling of urine ; incontinence, especially at night ; 
urine hot, dark-red, scanty, acid reaction, with strong odor ; 
ammoniacal., very offensive ; muco-purulent and phosphatic 
sediment ; patient pale, languid, with feeling of weakness in 
the loins. 

Camphora. — Strangury, discharge in drops ; tenesmus of 
the bladder ; retention or slow emission ; burning in the blad- 
der and urethra ; urine red, thick ; inflammation caused by 
Cantharides, Turpentine, etc.; coldness of the extremities; 
the urine has a musty odor. 

Cannabis IncLica. — -Burning, scalding, stinging in urethra 
before, during and after urination ; contains much mucus \ 
dribbles after stream ceases ; must wait before urine flows ; 
after exposure to cold ; aching in the kidneys ; thick, red 
urine. 

Cannabis sat. — Pain in neck of bladder and both kidneys, 
extending into inguinal glands ; urging every few minutes ; 
tenesmus worse after urinating. 

Cantharis. — Great inflammation, with hgematuria ; intense 
burning and cutting pains in the bladder ; violent tenesmus ; 
stinging, burning, cutting pains in the urethra ; violent inef- 
fectual urging ; discharge in drops which feel like hot lead 
passing through urethra ; constant desire to urinate ; urine 
scanty, turbid, bloody, albuminous, containing shreds of 
mucus. (Use the third decimal.) 

Chimaphila. — In both acute and chronic cases ; violent 
tenesmus ; urine scanty, high-colored, turbid, bloody ; abun- 
dant stringy sediment passed, with pain before, during and 
after; great difficulty in commencing to urinate; constipa- 
tion. (Use the first decimal.) 

Capsicum. — Spasmodic contraction, with cutting pains in 



TREATMENT OF CYSTITIS. 435 

the neck of the bladder ; burning, biting pain in the urethra 
after urinating ; scanty, light-colored urine. 

Coccus cacti. — Useful in chronic cystitis when the urine 
contains much uric acid and urates, and there is cutting pain 
and heaviness in the bladder and constant urging to urinate 
relieved by the act of urination. 

Conium. — In drop doses of the tincture, may sometimes re- 
lieve severe tenesmus. In the lower potencies for difficulty 
in voiding the urine or frequent urination at night, with 
pressing pain and stitches in the neck of the bladder, relieved 
by sitting, worse on motion. 

Copaiba. — Burning in neck of bladder and urethra ; urine 
passed in drops ; frothy, dark yellow, with odor of violets ; 
useful in acute cystitis, especially gonorrhoeal, or in irritabil- 
ity in old women. 

Cubeba. — Chronic cystitis; cutting after micturition; smart- 
ing during urination, last drops painful ; urine foamy, bloody, 
smelling like violets. 

Eucalyptus. — In chronic cases where the urine has an odor 
like that of violets and there is urinary fever. (Use first dec~ 
imal.) 

Gelsemium. — Frequent urging, with scanty emission and 
tenesmus ; spasmodic retention ; useful in post-diphtheritic 
paralysis of the sphincter. (Use the first decimal.) 

Dulcamara. — Cystitis from exposure to cold and damp, and 
in chronic cases aggravated by cold, damp weather, and when 
there is thickening of the muscular coats of the bladder; 
urine turbid and whitish, or reddish and burning when 
voided. 

Erigeron. — Useful in cases of very painful cystitis, with 
profuse, bloody, strong-smelling urine, and in cases of vesical 
calculus ; external parts inflamed and swollen. 

Equisetum. — Painful urination, with albuminous urine ; 
extreme and frequent desire to urinate, with severe pain, es- 
pecially just after the urine is voided ; dysuria during preg- 



436 DISEASES OF THE BLADDER. 

nancy and confinement ; nocturnal enuresis, weakness of the 
bladder, dribbling of urine, and pain as from over-distention. 
(Use first decimal.) 

Hyoscyamus. — Useful in spasmodic cases; retention of 
urine, bladder greatly distended, urine turbid ; mucous, puru- 
lent sediment ; great thirst, dry tongue ; subsultus tendinum ; 
delirium ; hysterical subjects. 

Lycopodium. — Chronic cases; calculi; urine frothy, milky, 
turbid ; offensive purulent sediment ; terrific pain in the back 
previous to every urination, with relief as soon as the urine 
begins to flow ; hsematuria ; haemorrhoids ; constipation ; flat- 
ulence ; copious, red, sandy deposits ; aching pain. 

Mercurius. — Pressure and heat in the perinseum ; in the 
rectum ; sudden irresistible desire to urinate ; sweat during 
urination ; region of the bladder sore ; urine turbid, dark red, 
contains shreds of mucus. Merc. cor. especially has great 
tenesmus and bloody urine. (Use third decimal.) 

Nux vomica. — Painful ineffectual urging to urinate ; dis- 
charge in drops with burning and tearing pains ; spasmodic 
retention of urine ; urine pale, or thick with purulent sedi- 
ment, or red with brick-dust sediment ; constipation ; haemor- 
rhoids ; after abuse of drugs ; useful in gouty cases. (Use the 
third decimal.) 

Pareira brava. — Constant urging, with tenesmus ; violent 
agonizing pain, especially in the early morning ; urine tur- 
bid ; much mucus ; ammoniacal urine. 

Phosphoric acid. — Constant urging ; urine milky, with 
bloody, jelly-like pieces of mucus ; decomposes rapidly ; burn- 
ing in the urethra while urinating. 

Piper methysticum. — Chronic cases with fetid urine ; stringy 
gelatinous sediment, very adherent. 

Petroleum. — Foetid urine of reddish -brown color, passed in- 
voluntarily. 

Phosphorus. — Bloody urine, w T ith pain in the region of the 
kidnevs and tension over the region of the bladder. 



TREATMENT OF CYSTITIS. 437 

Nitric acid. — Useful in the cystitis of elderly men where, 
immediately after urinating, there is intense desire to urinate 
again, with shuddering along the spine, especially at night, 
with a cutting pain in the abdomen and a cramp-like con- 
tractive pain from the kidneys to the bladder. 

Plumbum met. — Paralysis and atony of the bladder. 
Tenesmus and difficult urination. Patient lacks sensation to 
make the will act on the bladder. Urine mixed with blood. 

Polygonum. — Painful cutting and constriction in bladder 
continuing long after urinating ; pain in sacrum and bladder, 
not relieved by voiding large quantities of pale urine. 

Populus. — Urine scanty ; much mucous sediment ; violent 
tenesmus ; cystitis in elderly persons with severe tenesmus. 

Primus spin. — Terrific burning in urethra ; bladder is 
more comfortable when containing urine ; scanty urine of 
"brown color. 

Pulsatilla. — Frequent ineffectual urging with cutting pain 
at the neck of the bladder and tenesmus ; slimy sediment ; 
after exposure to cold. 

Sarsaparilla. — Chronic cases ; severe tenesmus ; emissions 
of white, acrid, turbid, flaky matter and mucus ; during mic- 
turition air passes from the bladder ; white sand in urine ; 
offensive smell of genitals ; abdomen distended ; pain and 
cramps in the bladder. 

Senega. — Vesical catarrh of old people ; dark urine, frothy, 
with mucous shreds, on cooling thick and cloudy ; great de- 
bility, weak legs, trembling and faintness on walking. 

Sepia. — Chronic cases ; full feeling in bladder, with down- 
ward pressure ; wants to hold up the abdomen ; periodical 
discharge of mucus, sometimes in plugs ; urine thick, slimy, 
highly offensive ; burning and cutting when urinating. 

Sandalwood. — Deep pain and uneasiness in the perinaeum ; 
sensation of a ball rolling in the neck of the bladder ; worse 
on standing, relieved by exercise. 

Thuja. — Frequent urging to urinate with profuse emission; 



438 DISEASES OF THE BLADDER. 

the urine is clear when voided, but is cloudy on standing 
(urates) ; there is brick -dust deposit (uric acid) ; burning in 
the urethra during and for some time after urinating ; stitch- 
like pain from the rectum to the bladder and from the blad- 
der to the urethra ; incontinence from paralysis and from re- 
tention. 

Sabal serrulata. — In cases of enlarged prostate with un- 
satisfactory micturition and intense straining ; patient has to 
wait for the first drop. 

Stigmata maydis. — Retention, tenesmus over entire abdo- 
men; constant desire to urinate, with urine containing mucus, 
blood and pus. 

Sulphur. — In obstinate cases, or when none of the preced- 
ing remedies prove efficient ; urine mixed with mucus and 
blood, with burning in the urethra when urinating ; impera- 
tive desire to urinate. 

Terebinthina. — Strangury ; tenesmus ; sensitiveness over 
the region of the bladder ; burning in the region of the 
kidneys ; sediment slimy, bloody ; urine retained from atony 
in old persons of sedentary habits ; congestion of the urinary 
organs. (Use first decimal.) 

Uva ursi. — Desire frequent, with burning, cutting pains ; 
urine high colored, with profuse, tough, mucous sediment ; 
burning and tearing in region of bladder ; constipation ; pain- 
fulness and soreness in the region of the kidneys ; uneasy 
feeling in the left thigh, with frequent desire to urinate ; 
pain and soreness in the left groin. 

Other remedies may be used as follows : 

Saw palmetto and Pulsatilla when there is chronic cystitis 
with enlarged and tender prostate. 

Triticum and Lycopus when there is delay and effort in 
starting the urine in chronic cystitis. 

Berberis in uric acid cases. 

Benzoic acid when there is incontinence of urine, especially 
at night. (Bruce.) 



TREATMENT OF CYSTITIS. 439 

If there is pus in the urine the following is useful : 

Benzoic acid, I part. 

Orange-flower water, 50 parts. 

Boiled water, 900 parts. 

Sugar. 100 parts. 

Take by the glass between meals. 

Cantharides and its analogues are standard remedies in 
cystitis, acute or chronic. For Cantharides itself the special 
indications are as follows : Very painful tenesmus, strangury, 
with very frequent emissions of small quantities of urine, which 
burns on being passed. It often contains albumin and blood 
in very considerable quantities. At other times it may con- 
tain considerable pus. In some cases the pains radiate into 
the kidneys and are associated with suppression of the urine. 
Useful in the cystitis following gonorrhoea, in that of tubercu- 
losis in the painful period when there is hematuria. Begin 
with caution, using third decimal, or even higher, increasing 
if necessary until two or three drops of the tincture are given 
at a dose. 

Palliative Treatment. — As is usually the case in a dis- 
order in which it is frequently impossible to remove the 
cause, and in one which is liable to acute exacerbations, we 
find a great variety of drugs used and palliative measures em- 
ployed. 

For the treatment of acute cystitis following gonorrhoea 
the following may be used : 

Give Gelsemium, first decimal, on account of the history, 
to be followed by, or in alternation with, such remedies as 
Belladonna, Cantharis, Cannabis sat, Ferrum phos. If there 
are good indications for any special remedy give it. 

Usually agonizing urination is the thing most complained 
of, and Chimaphila, Stigmata maydis, and Uva ursi have been 
the most satisfactory remedies. If blood is present Tere- 
binthina or Helonias may help the case. 

After the acute stage has passed and the patient has but 



440 DISEASES OF THE BLADDER. 

little pain on urinating, but complains of the imperative 
nature of the desire, Petroselinum is certainly of service in a 
great many cases. With this line of treatment nearly all of 
these cases get well. 

If the pain becomes too great to be borne a few doses of 
Salol, or the injection into the bladder of a small quantity of 
a two per cent, solution of Cocaine in a warm saturated solu- 
tion of Boric acid, rather than any form of Opium, is sug- 
gested. (E. M. Bruce.) 

Stigmata maydis in large doses, often as high as sixty 
minims of the tincture or fluid extract, has appeared to the 
writer to be of as much service in cystitis as almost any drug 
given internally. Combined with lithia in cases where the 
urine is hyper-acid. 

Uva ursi. — This drug in form of infusion or in ten to 
twenty-drop doses of the tincture is much used in cystitis- 
An infusion of the leaves may be made by adding one table- 
spoonful to a large glass of water ; to be taken three times 
daily. 

Chimaphila in ten to twenty-drop doses of the tincture may 
be used. Dr. C. W. Rose reports the following case of cystitis 
cured by Chimaphila : 

The patient, a man of 45 years, tall and weight about 170 
or 180, had been in the army, and ordinarily lived a quiet life. 
Had suffered in younger days from severe case of gonorrhoea, 
developing into gleet : 

" Gave twenty drops of Chimaphila tincture three times a 
day, also ten drops of Vesicaria that often, washing the blad- 
der out by aid of Calenduline and Pix-cresol, dissolved in hot 
water, every night. The first week saw not much, if any, 
change, except less pain in the bladder ; thereafter, however, 
I had the great pleasure of learning that urine became clearer, 
that less mucus was discharged. In fourteen days mucus al- 
most gone, no more blood at all. In three weeks patient re- 
ported as much better and happy. We now discontinued the 



TREATMENT OF CYSTITIS. 441 

washing of the bladder. I continued internal treatment, grad- 
ually reducing dose, when now I have patient on Cantharis 
3X, evidently getting well." 

In cases where there is no urethritis Cantharidin is some 
times used instead of Cantharis ; dissolve one milligramme of 
Merck's Cantharidin in a little alcohol, dilute with distilled 
water to make ioo c.c. (about three and a half fluidounces), 
and give a teaspoonful three times daily. 

Hydrangea is a useful remedy in cases where there is severe 
strangury. It may be alternated with corn-silk or combined 
with lithia. 

Thuja may be of use in controlling spasm of the bladder, 
given in doses of five drops of the tincture every three hours. 

Cannabis Indica is especially useful for controlling pain in 
acute cases. Use the tincture. 

Buchu is given in acute cystitis, either in doses of sixty 
minims of the fluid extract or combined with Hyoscyamus 
and Potassium bicarbonate in a pill. In cases of severe tenes- 
mus, as in gonorrhceal patients, the following may be em- 
ployed : 

Bromide of Ammonium, 10 parts. 

Tr. Hyoscyamus, 5 parts. 

Fluid extract Buchu, 10 parts. 

Distilled water, 60 parts. 

A coffeespoonful every four hours. 

Conium tincture in doses of two drops every hour may be 
serviceable in relieving tenesmus. 

Pichi. — For the distressing tenesmus in post-gonorrhceal 
cystitis this remedy is frequently serviceable. Wyman uses 
the following : 

Extract of Pichi, 10 parts. 

Tr. Cannabis Indica, 2 parts. 

Lime water, - 90 parts. 

A dessertspoonful every four hours. 

Oil of Erigeron. — This is given for the frequency of urina- 



442 DISEASES OF THE BLADDER. 

tion occurring in post-gonorrhceal cases ; ten drops on sugar 
may be given every three hours. 

Methylene (blue) in doses of i^ grains in capsules one to 
three times daily is given in chronic cystitis. The urine be- 
comes blue or greenish within five hours of the initial dose 
and remains so for several days after the last dose has been 
given. Toxic symptoms may be caused, and care must be 
taken to procure a pure article and to begin with small and 
infrequent doses. If powdered nutmeg be given at the same 
time, it is said that bladder irritation by it may be avoided. 
In spite of all objections to its use, great improvement in 
chronic cystitis is said to follow it. The following formula in 
elastic capsules is said to be desirable in avoiding gastric 
symptoms : 

#. Methylene-blue, i grain. 

Oil of nutmeg, . I drop. 

Oil of sandalwood, 2 drops. 

The above formula should not be used for more than ten 
days without intermission, and while giving it the patient 
should be instructed to drink freely of water. 

Urotropin may be serviceable in preventing decomposition 
of the urine and thus allaying irritation and pain. It should 
always be given in water for fear of irritating the bladder. 
The usual dose is seven and one-half grains two to four times 
daily. Five grains suffice in some cases, and in general the 
writer gives no more of it than absolutely necessary to pre- 
vent the urine from becoming ammoniacal. Even large 
doses of it, however, may fail to render the urine acid in re- 
action. 

Children may take as much as fifteen grains a day. Its 
chief value is to be found in the case of old men with cystitis 
from enlarged prostate, probably because in such cases the 
urine on leaving the kidney is acid, and the bladder-walls are 
not deeply penetrated by bacteria. The antiseptic body formed 



TREATMENT OF CYSTITIS. 443 

by the Urotropin first inhibits the growth of, and then kills, 
the bacteria that give rise to the alkalinity of the urine ; and 
the bladder freed from this source of irritation, will, if the 
drug is resumed from time to time, remain in a good condi- 
tion. (See Hypertrophy of the Prostate.) 

It may also be used with advantage in inflammatory condi- 
tions dependent upon atrophy of the prostate, new growths, 
and diverticula of the bladder, but in severe cases large doses 
may be required. 

In cystitis frorn spinal paralysis little can be accomplished 
by local treatment. Thirty-grain doses of Sodium hyposul- 
phite are highly recommended for hopeless cases. To make 
the urine acid give Benzoic or Boracic acid internally. 

In acute cystitis Arbutin in doses of from fifty to eighty 
grains a day and Buchu in teaspoonful doses of the fluid ex- 
tract every three hours are often given for the purpose of af- 
fecting the mucous membrane of the bladder. Dilute solu- 
tions of them are advised by Dr. Fitz. 

Striimpell commends Potassium chlorate, twenty grains in 
not less than six ounces of water, three or four times in 
twenty-four hours. It should never be given on an empty 
stomach. Its value is disputed. 

Cod-liver oil can be given for the emaciation and weakness 
sometimes occurring in protracted cases. 

Salol may be given in cases in which Urotropin is insuffi- 
cient as a disinfectant. The usual dose is five grains every 
three or four hours. 

Pills containing a great variety of substances are now in 
vogue for the treatment of cystitis. An example of these is 
seen in the following made by Parke, Davis & Company : 

Boric acid, . . I grain. 

Potassium bicarbonate, i grain. 

Extract Buchu, l / z grain. • 

Extract Triticum, . . ■ ■ ■ ■ % grain. 

Extract Corn-silk, % grain. 

Extract Hydrangea, ... X grain. 



444 DISEASES OF THE BLADDER. 

Atropine sulphate, YoVo grain. 

Extract Viburnum prunifolium, [ grain. 

For strangury (vesical tenesmus) immediate relief may be 
had from deep urethral instillation of Cocaine (four per cent.) 
or Silver nitrate (one per cent.). It is claimed that static 
electricity applied to the spine and hypogastric region allevi- 
ates this condition. 

Retention of Urine. — This may require hot baths, douches, 
Opium and Belladonna suppositories, with the remedies 
Aconite, Arnica, Hyoscyamus, Belladonna, Gelsemium or 
Veratrum. In a few hours, if no relief, the catheter must be 
used.' 

Surgical Measures. — These consist in washing out the 
bladder or opening the viscus and draining. 

Washing Out the Bladder. — Modern methods eschew the 
use of the catheter. A well-known instrument is that of 
Valentine, in which hydrostatic pressure suffices for the pro- 
cess, no catheter at all being used. 

B. M. Bruce has devised an apparatus of this sort by which 
the liquid, by care and gentle pressure, may be forced up even 
past strictures into the bladder. It consists of a heavy eight- 
ounce, salt-mouthed bottle, fitted with a double perforated 
cork. Through one opening is passed a right-angled glass 
tube (A), which must fit tight and extend only a little way 
below the inferior surface of the cork. To the distal end of 
it attach a double rubber pressure-bulb, with, say, some three 
feet of three-sixteenths-inch rubber tubing. Through the 
other perforation pass a similar tube (B), but it must extend 
to within one-quarter inch of the bottom of the bottle and be 
provided above the cork with a valve. To B attach a piece 
of rubber tubing (same size as to A), and some three feet over 
this tubing draw a four-inch glass funnel, with the bell opening 
toward the distal end. This is to catch the splash. Into the 
end of the tubing insert a piece of glass tubing about three- 
eighths-inch in diameter, drawn down so as to fit the meatus 



TREATMENT OF CYSTITIS. 445 

of the penis, and of sufficient length to extend two inches 
beyond the rim of the funnel. Fill the bottle with the solu- 
tion to be used. Open the valve in the tube (B) and gently 
press the bulb on the other tube ; as soon as the tube (B) is 
filled with liquid close the valve. 

The apparatus is now ready for use. Have the patient hold 
the glass tubing tightly in the meatus of the penis, open 
the valve and make a gentle pressure on the bulb. Wash the 
urethra out well before forcing any liquid up into the blad- 
der. Even if there are strictures, with care and gentle press- 
ure the liquid may be forced up into the bladder. Do not 
attempt to force in over an ounce or two at first ; allow the 
patient to pass this out and then repeat. Exercise the greatest 
care and judgment in increasing the amount of liquid injected 
for each washing. 

Solutions for Vesical Irrigation. — For irrigation a i : ioo 
Boracic acid or a i : iooo or i : 2000 solution of Carbolic acid 
is employed by Jousset. In very sensitive cases Bruce prefers 
to anything else the following : 

#. Fid. Ext. Hydrastis (non-alcoholic), ^iv. 

Boracic acid, . grs. xxx. 

Water, Oj. M. 

SiG. — Use at temperature ioo°-io5° F. 

After there is less sensitiveness one gets the best results 
from Potassium permanganate 1 : 8000 and gradually increas- 
ing to 1 : 4000. 

The bladder is likely to be very intolerant of liquids of a 
very low specific gravity as compared with urine, so that it is 
often desirable to add some Sodium chloride or Boracic acid 
to increase the specific gravity. Distilled water is almost al- 
ways painful. 

Occasionally there is a case which seems to stand still and 
some more active agent than Permanganate is necessary. 
Creoline has done good service a few times. Use it in from 
two to five drops to the pint. It is severe treatment, but oc- 
casionally brings good results. 



446 DISEASES OF THE BLADDER. 

Washing out the bladder by use of the catheter is only al- 
lowable when the urine stinks with ropy muco-pus, espe- 
cially when such a condition is the result of residual urine. In 
other cases renal abscess from ascending pyelitis is possible, 
especially after fifty years of age. (Fen wick.) 

Use of the Catheter. — Whenever the bladder becomes suffi- 
ciently distended to produce pain and the ordinary remedies 
fail to give relief, recourse is to be had to the catheter. Be- 
fore employing a soft catheter it must be soaked for ten min- 
utes in hot soap-water and flushed out with it ; then it is dis- 
infected with a strong germicide lotion, preferably corrosive 
sublimate, from which it must be freed again by another 
flushing with salt water before it is anointed with iodoform- 
ized vaseline for introduction. 

(The salt water should be tepid and, in strength, a tea- 
spoonful of salt to a quart of water. The iodoformized vase- 
line, should be 1:50 in strength.) 

A simple India-rubber tube is preferable for use in cases in 
which it can be passed. 

After use, the catheter should be again flushed out thor- 
oughly with carbolic or mercurial lotion, dried, and put away 
in a tight box or wide-mouthed bottle. If needed frequently, 
the catheter should be kept immersed in a five per cent, car- 
bolic lotion. Before using, however, the adherent carbolic 
lotion must be always removed by washing in salt water. 
(See also Hypertrophy of the Prostate.) 

Injections may be made by use of an ordinary fountain- 
syringe. Whatever solution be used, the temperature of it 
should be ioo° F. when it reaches the bladder, say, 105 to 
no° in the syringe. 

In giving injections an ounce or two only of fluid at a time 
should be used first, and pain should not be inflicted. The 
water, after remaining in the bladder for a few moments 
should be allowed to run out. It will bring with it at first 
whatever substance is mixed with the urine — always mucus, 



TREATMENT OF CYSTITIS. 447 

sometimes pus and mucus. The injection should be repeated 
until the water runs away clear. After a time there will 
either be an improvement in the bladder itself, or it will have 
grown accustomed to injections, when larger quantities of 
water, and often of much higher temperature, may be intro- 
duced. 

In cases of eccentric hypertrophy use of the catheter is 
often necessary. 

In cases of concentric hypertrophy, on the other hand, the 
patient should be urged to hold his urine. 

Catheter Fever. — In cases of chronic retention of the 
urine death sometimes results from removal of too much 
urine, due to catheter fever or urinary fever, so called. 

According to Klophel, in operations for the relief and cure 
of chronic retention of urine the complete evacuation of all 
the urine at first should not be permitted, but rather the 
withdrawal of a few ounces and the immediate injection of a 
solution of Boracic acid in volume equal to one-half of 
quantity of urine withdrawn, lessening at each succeeding 
injection the quantity of fluid thrown in and increasing the 
amount of urine withdrawn. Thus, by regular gradation, 
the bladder is emptied and the circulation in its abnormal 
walls is accommodated by degrees to the new order of things. 
The same may be said of the ureters and of the kidneys. 

It must be carefully borne in mind that in nearly all chronic 
diseases of the lower urinary tract the kidneys become in- 
volved in time. 

In washing out the bladder a soft catheter is to be used. In 
most cases a simple India-rubber tube is sufficient, one end of 
which is slipped over the end of an ordinary syringe. By 
nipping the tube the liquid can be retained or the syringe re- 
filled without trouble. After micturition the soft catheter or 
tube is passed and any urine left behind drawn off. Several 
ounces of lukewarm water are now injected and the catheter 
is withdrawn a little so that the end is brought to the neck 



448 DISEASES OF THE BLADDER. 

of the bladder. On now opening it the organ is completely 
emptied. The injections should be continued until the re- 
turning liquid is quite clear. The patient should stand dur- 
ing the process, for in this way the sediment is most readily 
evacuated. After the bladder is washed out antiseptic solu- 
tions may be introduced. 

Solutions Used in Washing Out the Bladder. — Three per 
cent, solution of Boracic acid is a favorite ; one-fourth per 
cent. Cocaine, one-half per cent. Resorcin, one-sixth per cent. 
Carbolic acid, five per cent. Sulphate of Soda are used ; 
also, ten drops tincture of Opium in ioo c.c. of water. As- 
tringent injections are one-half per cent. Alum, one-fourth 
per cent. Zinc sulphate or Carbolate, one-fifteenth per cent. 
Potassium permanganate, two per cent. Tannin, one-tenth 
per cent. Silver nitrate. When the urine is very offensive 
and strongly alkaline any of the following may be used r 
One-tenth per cent. Potassium permanganate, lukewarm water 
with a few drops of Amyl nitrite, half a liter (one pint) of 
water containing three to five drops of Amyl nitrite, one- 
tenth to three-tenths per cent, solution of Salicylic acid, one- 
half per cent. Creolin solution, twenty-five per cent, solution 
of Peroxide of hydrogen. When there is a heavy sediment 
of phosphates, one-tenth per cent, solution of equal parts Hy- 
drochloric acid and Carbolic acid, or two-tenths per cent, so- 
lution of Salicylic acid, or two per cent. Salicylate of Sodium. 

In bacteriuria, i in 10,000 of Corrosive sublimate. 

Supersaturated solution of Boracic acid may be made as 
follows : Add to one hundred parts of boiling water fifteen 
parts of Boracic acid and one part of calcined Magnesia ; let 
cool. Lavaux has used this solution successfully in chronic 
cystitis when the ordinary four per cent, solution failed to re- 
lieve. Poisoning from the use of Boracic acid injections is 
occasionally reported. 

Hydrogen dioxide may be used as follows : First neutralize 
with Magnesium carbonate, adding the latter until the solu- 



TREATMENT OF CHRONIC CYSTITIS IN WOMEN. 449 

tion fails to redden litmus, then add an equal volume of water, 
inject and follow with a Boric acid wash. 

Glyco-thymoline, Pix-cresol and Oxy chlorine are also used. 
One of the writer's severely painful cases was considerably 
relieved by use of Glyco-thymoline washes. After washing 
out the bladder with Boric acid solution Calenduline may 
be injected. The bladder may be washed out with normal 
salt solution and ten grains of Urotropin^ dissolved in one 
ounce of mucilaged water, may be injected and left in. In- 
stead of Urotropin the substances known as Aminoform or 
Cystogen may be employed. 

Citrate of Silver, i to 4,000 or 1 to 10,000 and Protargol ; 
also Potassium permanganate, 1 to 4,000 ; Oil of Cloves in 
one-quarter to one-half per cent, solution are recommended 
by Goldspohm. 

Instillation is another means of treatment and consists in 
introducing more concentrated solutions in much smaller 
quantities. In this manner are used Silver Nitrate, 1 to 2 
per cent., Bichloride of Mercury, 1 to 5,000 to 1-500, and 5 
to 10 per. cent, emulsion of Iodoform. Rovsing recommends 
40 c.cm. of a 2 per cent. Nitrate of Silver solution, and says 
that so certain is the action of this remedy that if it does not 
benefit, a complicating pyelitis may be assumed. (Gramm.) 

In cases in which after operation the urine still remains 
cloudy, irrigation with twenty per cent. Glyco-thymoline solu- 
tion may bring about perfect recovery according to G. W. 
Hopkins, of Cleveland. 

Drainage of the bladder is indicated in cases of chronic 
cystitis and is useful in cases of enlarged prostate, when no 
radical operation is allowed, because of the slight shock com- 
pared with that of operations on the prostate. itself. 

TREATMENT OF CHRONIC CYSTITIS IN WOMEN. 

In general we must depend upon the following measures : 
1. Rest, diet, baths and applications. 
29 



450 DISEASES OF THE BLADDER. 

2. Cure of any uterine or ovarian disorder present. Em- 
ployment of plastic surgery. 

3. Persistent catharsis if necessary. Internal use of urinary 
disinfectants, as Urotropin. 

4. Dilatation of trie urethra. 

5. Surgical operation. 

In acute cases rest, in a recumbent position, with a diet 
of milk, copious diluent drinks, mucilaginous drinks, hot 
sitz-baths, copious vaginal douches and hot turpentine 
stupes or bran bags to the hypogastric region will give relief. 

In case of severe pain anodynes for rectum, as above de- 
scribed. 

Persistent catharsis is sometimes a useful measure. 

If there are diverticula as in cystocele or procidentia uteri 
this cause must be removed. 

If the inflammation extend from the appendix, uterus, 
tubes, ovaries, or from pelvic exudates, these sources of in- 
flammation must be treated. 

If the urine is hyper-acid, Citrate of Potassium or Lithium 
should be given in doses of from fifteen to twenty grains, if 
necessary, three times daily. 

When there is mixed bacterial infection and alkaline urine 
Benzoic acid, in ten grain doses, or Ammonium benzoate can 
be used. 

If Urotropin fails, then try Boric acid in ten grain doses 
every three hours, or Salol in five grain doses when the urine 
is ammoniacal. In gonorrhceal cases Copaiba, Oil of Sandal- 
wood and Oil of Eucalyptus in capsule (five to ten minim 
doses). 

Cystitis in women must not be mistaken for irritability of 
the bladder. In the latter case micturition is frequent and 
may be painful, but is relieved when the bladder is empty 
and the urine is free from pus. Pledgets of cotton dipped in 
a five per cent, solution of Cocaine hydrochlorate and inserted 
one by one into the urethra may relieve the pain in simple 
irritability. 



TREATMENT OF CHRONIC CYSTITIS. 451 

In chronic cystitis, however, we may find much difficulty 
in relieving the patient. 

Attention must be paid to the cause of the disorder. The 
pain and frequency may be due to caruncle in the urethra. 
Other urethral diseases may be the cause of the unpleasant 
symptoms, as chronic congestion or suppurating cyst of the 
urethra, abscess of the urethro-vaginal septum, or a tender, 
congested condition of the urethral mucous membrane. 
Chronic congestion of the urethra is chiefly seen in pregnant 
women ; the urethra is swollen and tender and feels like a 
thick cord. Not only the act of micturition, but sexual in- 
tercourse may occasion almost unbearable suffering. 

Rectal and anal troubles are a frequent cause of cystitis in 
women, as are uterine displacements. 

Uterine and ovarian disorders must be cured, as a rule, be- 
fore the treatment of cystitis can be effectual. 

According to Morris, fissure of the neck of the bladder is 
apparently much more commonly met with than fissure of 
the anus, but seldom recognized. The fissure can be seen by 
gently distending the urethra with proper specula and throw- 
ing in light with a head mirror. It is a narrow, grayish ulcer, 
similar to a narrow aphthous spot in the mouth. The pri- 
mary symptoms are pain on urination, lasting tenesmus after 
urination and frequent urination. Secondarily come catarrhal 
cystitis and nervous derangements. The ulcer may be caused 
by the compression of folds of the urethral mucous mem- 
brane, by a uterus out of place, from a scratch, by the passing 
of a bit of gravel, or it may be simply microbic, as the aphthae 
of the mouth are now known to be. 

The various causes for cystitis must, therefore, be attended 
to before we can expect much benefit from general treatment. 
For caruncle E. S. Bailey, of Chicago, uses the electric needle. 

For urethral fissure the treatment consists in dilating the 
urethra slowly with the finger, to accomplish the same end as 
when we stretch the sphincter of the anus for fissure in that 



452 DISEASES OF THE BLADDER. 

locality. Immediately after urination a few drops of a five 
per cent. Cocaine solution injected at the neck of the bladder 
will at once control the painful tenesmus. The wool tampon 
for the vagina will give a feeling of great comfort and lessen 
the tendency to spasm of the bladder. Absorbent cotton 
should never be used for the tampon, because when it becomes 
stony in a few hours it irritates the bladder, just as it usually 
does the uterus. 

The above treatment failing to cure, the bladder should be 
opened to give the urethra rest. This is done by introducing 
a Sims uterine dilator through the urethra, pressing the blad- 
der-wall backward and then slipping a scalpel through the 
wall between the blades, entering from the vaginal surface. 
In one aggravated case, recently, Morris opened the bladder 
above the pubes and poured into it, twice daily, an ounce of 
a mixture of Boroglyceride and Glycerin. Boroglyceride 
and Glycerin is the best thing for any sort of hypertrophic 
catarrh. Clots in the bladder should be digested out with 
Pepsin. If the bladder is acidulated with Citric acid, Pepsin 
will digest the thick tenacious muco-pus quickly and give 
patients great relief. . In old cases, with contracted bladder, 
expansion daily with Davidson's syringe and warm Boric acid 
solution will gradually enable the bladder to hold a pint or 
more of urine. 

Dilatation of the urethra may be helpful in cases where 
tenesmus is a distressing feature and in which the parts 
around have become contracted and hypertrophied. Faradism 
with one pole near the uterus and the other over the bladder 
may give great relief. 

If no organic changes have taken place, injections of Mer- 
curic chloride solution, i to 2,000, will help a train of symp- 
toms due to suppuration, uncleanliness and the like. 

Dr. Madden, of Dublin, treats severe cystitis in women by 
dilating the urethra, which permits a continuous outflow of 
the secretion ; this treatment, together with mild washing of 



TREATMENT OF CHRONIC CYSTITIS. 453 

the bladder, usually effects a speedy cure. If not, the fundus 
and neck of the bladder should be wiped with a bit of cotton 
soaked in carbolized Glycerin and passed through the dilated 
urethra. The use of Cocaine will prevent the pain of the 
operation. 

In general, before any operative interference is undertaken, 
the urine should be normally acid ; this can generally be ac- 
complished by the free use of Citric acid in the shape of 
lemonade or lemon juice and water ; the mineral acids act 
more slowly, and Benzoic acid is not often well borne by the 
stomach if administered for too long a period of time. The 
use of Citric acid in one day has been known to remove a 
thick phosphatic crust on the edges of a vesico- vaginal fistula, 
or on the wound through the perinseum in lateral lithotomy. 

General Treatment. — Rest is essential and probably of 
more value than washing out the bladder. Lying on the 
stomach in bed is advisable. 

Special attention is given to diet: Bread and milk, soft- 
boiled eggs, toast, chicken, baked potato and milk, dipped 
toast, hasty pudding and such articles of diet have the 
preference ; especially avoid tea, coffee, spices and anything 
which may increase irritation of the kidneys. 

The bowels are to be regulated with great care. Either 
Rubinat water or Tarrant's aperient are usually well liked by 
women and are efficacious. 

Where there is prolapse or misplacement of the uterus use 
ring pessaries of tarred jute, which are very acceptable to the 
patients. 

Besides the injections into the bladder use hot sitz-baths, 
once or twice a week, together with injections into the vagina 
of hot water with Boroglyceride. 

After the injections use suppositories of Boroglyceride, and 
where the pain is sufficiently severe to warrant its use add a 
sufficient quantity of Morphine to allay the pain. 

In acute cases cataplasms, baths and hypogastric fomenta- 



454 DISEASES OF THE BLADDER. 

tions are useful. Topical applications in the vagina assist in 
allaying inflammation about the neck of the bladder : 

Camphorated lanolin, ^ij. 

Extract of Belladonna, 3 j. 

Saturate a tampon with the above and introduce night and 
morning into vagina. 

When the pain is intense apply in the same way : 

Muriate of Cocaine, gr. xv. 

Distilled water, f 3 vj. 

Internally, for the acute form of cystitis : 

Oxalic acid, . . gr. viij. 

Distilled water, f^iij- 

Syrup bitter orange-peel, . . . f ^j. 

A dessertspoonful every four hours. 

For insomnia, Chloral per rectum as follows : 

Chloral hydrate, • 3J. 

Yellow of one egg, 

Water or milk, f^iiss. 

(Lutaud.) 
The following cured one of Hale's cases in four days : 

Bi. Balsam copaiba, £ ss. 

Oil sandalwood ^ss. 

Oil cinnamon, . ^i. 

Emulsion acacia, Bjiiiss. 

Simple elixir, S^j- 

Sig. — A dessertspoonful every four hours. 

Unfortunately, however, we have no information as to the 
cause or character of the malady in this case. 

In many cases internal use of Aminoform or Urotropin 
will prove curative, prevent ascending pyelitis and lessen the 
need of surgical interference. 

TUBERCULOSIS OF THE BLADDER. 

Etiology. — The disease is rarely primary. If primary, the 
trigonal submucosa is by far most likely to surfer. The cause 



TUBERCULOSIS OF THE BLADDER. 455 

is generally tuberculosis of a neighboring or associated organ. 

In rare cases it is directly secondary to tuberculous disease 
of the lungs or intestines. When it is part of a urogenital 
tuberculosis, the starting point may be the kidney, or the pros- 
tate, or seminal vesicle. 

Occurrence. — It occurs usually in young patients, from fif- 
teen to twenty-five years of age, with family history of tuber- 
culosis or cancer, and personal history of masturbation, with 
increasing frequency of urination, or of chronic inflammatory 
disease of the urogenital tract. It is most common in men 
under the age of forty, but may also occur at the extremes of 
life. 

Pathology. — The bladder may be invaded in two ways : 
First, and more commonly, by surface inoculation by the 
stream of tuberculous urine from the kidney or its pelvis ; 
second, by continuity along the line of the ureter, or from the 
prostate or seminal vesicles. 

Tuberculosis of the kidney may not, if the bladder is 
healthy, necessarily infect the bladder, but an unhealthy con- 
dition of the inner bladder wall or instrumentation may give 
rise to infection of the latter ; or the germs may be introduced 
into the bladder upon unclean instruments, or be dislodged 
from the urethra and carried back. The bacilli may, in some 
cases, enter the bladder from some remote tubercular lesion 
through the blood or lymph channels. 

Tuberculosis in the bladder presents itself as an infiltration 
about the mouth of the ureters and the neck of the bladder. 
Ulceration occurs early, extends to a varying depth, often 
undermining the mucosa, and occasionally perforating into 
the perivesical tissue or rectum. Tubercles may be seen on 
the floor of the ulcers. Cystitis and hypertrophy of the blad- 
der are generally associated with it. 

Irritating products of tubercular inflammation affect the 
trigonal mucous surface, causing symptoms resembling gon- 
orrhoea! cystitis. If, then, an excoriation takes place from 



456 DISEASES OF THE BLADDER. 

the irritation, or a rent is made by an instrument, tubercular 
infection is easily accounted for. 

Extension by continuity from the ureter results in swelling, 
congestion, excoriation, and finally ulceration. 

Diagnosis. — The disease is to be suspected when a patient 
between fifteen and thirty-five years of age complains of fre- 
quent micturition and slight haematuria aggravated by a re- 
clining position, and where there is a tubercular family his- 
tory or tubercular nodules can be found in the epididymis, 
vas, prostate, lungs, or other organs. (Carleton). 

Clinical Features. — In primary cases of invasion of the 
middle coat of the bladder from the blood- vascular channels 
the symptoms are none, or but slight. If any, they are usu- 
ally as follows : 

Slowness in starting the stream, weakness of flow, and diffi- 
culty in emptying the bladder. 

Residual urine in more or less quantity in later stages. 

Gnawing pain behind the pubes when the bladder is dis- 
turbed, not quickly relieved by urination. 

Slight haemorrhages from over-distension. 

In other words, symptoms closely resembling those of ob- 
structive prostatic disease. 

In secondary cases the features are those of stone in the 
bladder (See Stone in the Bladder), except (i) that the 
frequency of micturition is not relieved by rest, (2) the pain 
is referred to the centre of the penis or is felt in the peri- 
naeum. 

In women haematuria is often the first symptom and is gen- 
erally accompanied by a pulpy growth around the meatus. 
(Carleton.) 

The first symptom is usually frequency of urination, espe- 
cially at night, finally becoming almost incessant. Retention 
or incontinence may occur, the latter in the ulcerative stage. 

Pain may be felt before, during and after urination. 

In half the cases haematuria is the first symptom. The 



TUBERCULOSIS OF THE BLADDER. 457 

amount of blood varies from a few drops to profuse and even 
fatal haemorrhage. 

When cystitis is established, the pain becomes severe or 
even agonizing ; tenesmus and retention may take place from 
the lodging of clots in the urethra, with consequent pain in 
the supra-pubic and perineal regions. 

The Urine. — This presents no characteristic features other 
than may be found in any diseases of the bladder in which 
blood, pus, phosphates, and debris occur, save for presence of 
the Bacillus tuberculosis. For detection of this bacillus see 
Renal Tuberculosis. 

Course. — The disease pursues a chronic course with acute 
exacerbations. In the earlier stages the health is not much 
affected. In some cases it does not prevent a long duration 
of life. The onset may be gradual and insidious. 

Differential Diagnosis. — Vesical tuberculosis is to be dif- 
ferentiated from vesical calculus as follows : 

Absence of history of passage of renal calculus. 

Exercise does not cause so marked an increase of vesical 
irritability. 

The pain is in the middle of the penis, and does not pass 
forward under the glans. 

The sudden arrest of the stream relieves the pain. 

Nocturnal frequency rapidly increases, depending on disten- 
tion reflex. 

Evidences of a contracting bladder are present. 

Presence of tubercular products in the urine. 

Cystoscopic examination shows no stone. 

V T esical tuberculosis coming from an infected seminal vesicle 
can be distinguished from vesical calculus as follows : 

In tuberculosis from this cause the bladder is unable to 
hold more than five or six ounces ; the pain ceases when 
about half of this is voided ; there is much straining at the 
end of urination, and extrusion of a few drops of blood ; the 
distress subsides as the bladder is partly filled ; day and night 



458 DISEASES OF THE BLADDER. 

frequency is about the same ; the cystoscope shows a patchy 
inflammation along the side of the affected vesicle only. 

Primary vesical tuberculosis can be differentiated from ob- 
structive prostatic disease by observation with the cystoscope 
that a patchy disseminated tuberculosis is present under the 
transparent mucous lining of the bladder. 

Vesical tuberculosis coming from the prostate must be dis- 
tinguished from cystitis of the neck. Differential diagnosis 
is to be made as follows : The finger in the rectum detects an 
unusual sensitiveness in the intervesicular space, especially if 
the bladder is partly filled. Distention reflex is marked. 
Nodules may sometimes be felt in the bladder wall. The 
detection of the disease in the prostate usually serves to do 
away with the necessity of instrumentation. 

In general, use of the cystoscope for diagnostic pitrposes en- 
ables us to do away with that of the stone-searcher, a most 
dangerous instrument in tuberculous cases. 

When a tubercular condition of the kidney extends to the 
bladder, the clinical symptoms resemble closely those of renal 
calculus ; when it extends from the seminal vesicles, it simu- 
lates vesical calculus, and presents as a clinical picture fre- 
quent desire to urinate, caused by a contracted vesical cavity ; 
often in the early stage it will not contain more than four 
ounces of urine. In the last stages the thickening of the 
bladder walls may be so marked that the viscus will not con- 
tain more than one or two ounces. Pain is relieved when the 
bladder is half empty. The act of micturition is followed by 
a few drops of blood. 

When the lesion originates in the prostate, in conjunction 
with evidences of acute prostatitis and haematuria, a rectal ex- 
amination will reveal an enlarged nodular gland, etc. In 
tubercular cystitis retention of urine only occurs when the 
neck of the bladder or prostate is involved. (Carleton.) 

Treatment. — In early stages of primary vesical tuberculosis 
a cure may be obtained from supra-pubic cystotomy, curette- 



TUBERCULOSIS OF THE BLADDER. 459 

ment or cautery of the lesions, or destruction of these by 
means of Lactic acid applications, rubbing in of Iodoform 
thoroughly into the diseased area, followed by drainage for a 
few weeks, bladder irrigation with solution of Mercuric chlor- 
ide 1-2,000 to 1-20,000 being made daily. 

In extreme cases the bladder has been removed and the 
ureters implanted in the intestines or rectum. 

In general, where operative measures cannot be undertaken, 
the following treatment should be carried out : 

1. Residence in climate suitable for tuberculosis. 

2. Avoidance of chill. 

3. Use of nourishing, easily-digested food, containing as 
much fat as can possibly be digested. 

4. Hydrostatic bladder irrigations of solutions of normal 
salt, weak Salicylate or Borolyptol, or injection of emulsions 
of Iodoform. 

Iodoform injections may be made as follows : Three or four 
ounces of a five per cent, solution of Iodoform in liquid vase- 
line are injected into the bladder every two or three days, the 
patient being instructed to watch the stream when he urinates 
and stop the flow just as soon as the oil appears. This forms 
a permanent Iodoform dressing of the bladder-wall, and in the 
hands of some of the French surgeons is said to have met 
with gratifying results. 

Picot prefers to use olive oil instead of vaseline, as the 
latter has been known to furnish a nucleus for calculus. His 
formula is Guaiacol, 5 parts ; Iodoform, 1 part ; sterilized 
Olive oil, 100 parts. Ten to twenty drops are injected daily. 

Alfred K. Hills uses irrigations of Borolyptol, in strength 1 
in 8 to 1 in 16, relieving disagreeable subjective symptoms by 
internal administration of a mixture containing 10 minims of 
the tincture of Belladonna, 15 grains of Benzoate of Sodium, 
and oil of Gaultheria to make one drachm ; given three times 
daily. 

After irrigation by any agent instillations of from ten to 



460 DISEASES OF THE BLADDER. 

forty drops of Mercuric chloride solution, (strength ?) repeated 
every two or three days, have been well spoken of. (Carleton.) 

The remedies used most commonly are Cantharides for the 
pain and hsematuria (not in large doses), Guaiacol or Creosote 
in doses of from three to twenty drops, three times daily, 
given for a long period. 

The oils of Sandalwood and Cubeb have also been em- 
ployed. 

Tuberculocidin, Klebs, has been used successfully by Roerig 
in the treatment of tubercular ulcer of the bladder. 

The ulcer was situated between the urethra and the right 
ureter (tuberculous cystitis). The bladder was very sensitive 
and held sixty ccm. The subjective symptoms were severe. 
Various therapeutic measures were tried unsuccessfully, such 
as instillations of Guaiacol-iodoform emulsion, later 1:5,000 
corrosive sublimate, and stronger, with cleansing of the ulcer. 
Tuberculocidin, Klebs (Tct), was then used, at first five drops, 
which was increased gradually to forty drops a day. Once 
in two or three weeks the instillations of sublimate were re- 
peated. The Tuberculocidin was also used locally by inject- 
ing five grains of the tincture into the bladder just after emp- 
tying it. The results of three months of this treatment were 
remarkably good. The patient was able to work, free from 
pain, slept normally, had no tenesmus, and an increased blad- 
der capacity. 

SYPHILIS OF THE BLADDER. 

This is said to occur, but is exceedingly rare. 

TUMORS OF THE BLADDER. 

There is a marked tendency on the part of tumors of the 
bladder to be polypoid. Other kinds, however, may occur. 

Classification. — A division of bladder-tumors may be made 
as follows : 



BENIGN GROWTHS. 461 

I. Benign. — Papilloma, myxoma, liomyoma, fibroma ; rarer 
forms : angioma, cysts. Cysts hydatid, dermoid and serous ; 
they are rare. 

II. Malignant. — Sarcoma and cancer. Sarcoma shows the 
following varieties : Fibro-sarcoma, lympho-sarcoma, myo- 
sarcoma, round-cell and spindle-cell. Cancer is either flat-cell 
or glandular. 




Fig. 2S— Vesical Polyp.— (From Thompson.) 

Papilloma is the most frequent of benign growths, carcinoma 
of malignant. Sarcoma is, however, not so rare as formerly 
thought. 

Occurrence. — Middle life is most subject, except in the case 
of myxoma, which is more often found in childhood. Males 
are more liable than females. The lower third of the bladder 
is more liable to growths than the upper two-thirds. 

Secondary carcinoma as the result of extension of uterine 
or vaginal carcinoma is comparatively frequent in women. 
Women in fuchsin factories are said to be especially liable to 
bladder-tumors. 

BENIGN GROWTHS. 

Papilloma. — A rather common tumor is the soft or villous 
papilloma a pediculated or sessile growth having its most fre- 
quent seat in the region of the trigone. (Fig. 29). It may 
be small and slender, projecting like a tendril into the bladder 
or it may be a large cauliflower-like mass. 



462 DISEASES OF THE BLADDER. 

The pedicle varies in length, thickness, and structure. It 
may be as long as an inch or more, and it varies in size from 
that of a knitting-needle to that of the thumb, or larger. The 
structure of the papillae is as follows : Their base is made up 
of unstriped muscular fibre and connective tissue. From this 
spring the individual papillae. Each of the latter consists of 
a delicate framework of connective tissue, through the centre 




Fig. 29.— Papilloma of the Bladder.— (From Thompson.) 

of which run loops of capillary blood-vessels with very deli- 
cate walls, lined with endothelium, bearing endothelia with 
large nuclei. Externally each papilla is covered with one or 
more layers of epithelium of columnar form with large nuclei; 
these are of the same type as the epithelia of the deeper 
layers of the normal mucous membrane of the bladder. 

Sometimes the tumor occupies an extensive area along the 
surface of the urinary tract. Bleeding is very common and 
may lead to grave consequences. 

Not rarely villi become detached and appear in the urine. 
The tumors though benign tend to recur after removal and oc- 



BENIGN GROWTHS. 463 

casionally seem to become carcinomatous or to ulcerate. Cys- 
titis accompanies them as it does other tumors of the bladder. 

Myxoma, or polyp, is a single growth, pedunculated, and 
resembling in gross appearance nasal polypus. (Fig. 28.) 

A mucous polyp occurs but rarely but it may be of inflam- 
matory origin rather than a true tumor. 

Myomas are rare, only about sixteen cases being known, 
but they have been found in both sexes and at the two ex- 
tremes of age. 

They are very analogous in their character and structure to 
uterine fibromas. They spring from the thickest part of the 
muscular wall of the bladder, and extend either on the out- 
side or inside of that organ, hence the division into "myom.es 
excentriques " and "myomes cavitaires." (Albarran.) The 
latter are the more frequent. They may be sessile or pedicul- 
atecl, and their size may vary from that of a nut to that of an 
adult's head, and even larger. They are usually very limited, 
encapsulated, and easily enucleated. 

In the case of a " myome excentrique," there are scarcely 
any vesical symptoms; the myoma only betrays its presence 
by the slow growth of a tumor which hinders the function of 
neighboring organs. 

In the case of a "myome cavitaire," the ordinary symptoms 
of vesical neoplasms are observed : frequent hsematuria, pain- 
ful micturition, sense of weight in the peiinseum or hypogas- 
trium. 

By rectal or vaginal examination, especially when combined 
with abdominal palpation, the presence and nature of these 
tumors may often be made out. 

The progress of these myomata is variable ; death is often- 
est the result of the secondary accidents of infection. (Ter- 
rier and Hartmann.) 



464 DISEASES OF THE BLADDER. 



MALIGNANT GROWTHS. 



Carcinoma. — The stroma of a carcinomatous growth, com- 
posed of the tissue of the submucous and vascular layers of 
the bladder, with more or less round-celled infiltrations, is full 
of alveoli, well packed with epithelial cells, following with 
more or less accuracy the types of the bladder epithelium. 
The formation of cancer " nests " varies much in different 
specimens, and often in different parts of the same specimen. 

Squamous epithelioma is. the usual type of malignant epi- 
thelial growth. It may be villous or infiltratory, the latter 
causing marked thickening of the bladder wall. Horny 
change and metastasis are rare. 

Sarcoma is rare, is usually large in size, multiple, situated 
about the orifices and sometimes infiltrates the bladder wall, 
causing an enormous thickening. Sarcoma has been found 
in the bladder in one case which was that of a worker in a 
fuchsin factory. 

Diagnosis. — The cystoscopic examination of the bladder is 
the surest means. Intermittent hsematuria and pain in the 
bladder should suggest the presence of a tumor. 

Clinical Features. — These are the following : 

i. Hsematuria preceding pain in benign growths and often 
in the beginning symptomless. 

2. Pain or irritability of the bladder often preceding hsema- 
turia in malignant growths. 

3. Relief of pain after an attack of bleeding. 

The hsematuria of bladder-growths may take place even 
during sleep, is very abundant, and shows progressively in- 
creasing frequency and abundance as the disease progresses. It 
is, as a rule, intermittent. 

Occasionally hsematuria is continuous. 

Instrumental manipulation within the bladder is liable to 
produce hsemorrhage, and one or two fatal cases from this 
cause are on record. 



MALIGNANT GROWTHS. 465 

The pain is not, as a rule, increased by exercise. 

In malignant growths pain is a prominent symptom sooner 
or later, and is frequently of a radiating character. In excep- 
tional cases pain may be absent. 

Frequency of micturition is not more noticeable at night. 

In several cases of bladder tumors which the writer has 
seen a remission of symptoms has followed attacks of haema- 
turia, the patient has insisted that nothing serious was the 
matter with him and operation has been refused. 

Bnormous clots of blood may be voided, some of them or- 
ganized and comparatively firm in consistence. 

Tumors of the bladder may grow about the urethral orifice, 
cause hydro- and pyo-nephrosis, and death, with renal symp- 
toms, suggesting Bright's disease. 

In one of the cases mentioned above, in which operation 
was refused, the patient ultimately died of uraemia. 

In one other case a prominent feature was great pain and 
straining with the passage of the clots. 

The first symptom of hsematuria is often followed by an 
impediment to urination and to mechanic obstruction of the 
orifice of the urethra. Later we have the kidney-ache, which 
is caused by the ascending inflammatory changes and is felt 
on the side on which the tumor is located. These symptoms 
are sooner or later followed by a cystitis, unless great care is 
exercised in the management of the case. This confuses the 
diagnosis, complicates the disease, and may eventually end the 
life of the patient by developing a pyonephrosis. (Wathen.) 

Carcinoma of the bladder is often concealed by the presence 
of chronic cystitis and is sometimes associated with stone. 
In the writer's experience it is difficult to recognize in certain 
cases. It should always be suggested by pallor and rapid loss 
of flesh in elderly patients who have cystitis, even if stone is 
also present. Induration of the inguinal glands is sometimes 
of service in the diagnosis as is palpation by the rectum or 
vagina with discovery of an indurated area in the bladder. 
30 



466 DISEASES OF THE BLADDER. 

Scratches on ^ the catheter are serviceable in making the 
diagnosis, inasmuch as the growth may be covered with 
crystals. Fragments of the growth may be found in the 
fenestrum of the catheter. 

In rare cases in women Kichhorst has observed the growth 
projecting into the urethra. There may be severe pain in 
the hypogastric region at night radiating into the loins and 
thigh, retention or incontinence of urine, and febrile symp- 
toms if the urine decrease in amount. 

In a case which the writer saw the chief features were 
frequency of urination, pain on urinating, especially at night 
and great restlessness and nervousness. There had been 
hematuria in the past but none was observed while the 
patient was under the writer's observation. 

The Urine. — The features are the following : 

Presence of blood. 

Presence of bits of the surface of the growth. 

In malignant disease large numbers of epithelia of a great 
variety of shapes, with many and large nuclei. The quantity 
of these epithelia is of importance. 

In order to find the bits of growth, the writer has resorted 
successfully, in one or two cases, to the following simple 
method : 

The urine is diluted with water until the blood-corpuscles 
are in large part dissolved, after which sedimentation in the 
centrifuge will easily collect the particles, if present, which, 
if examined with the microscope, show great abundance of 
connective-tissue shreds. (See Urinary Analysis, p. 315.) 

In fibrous polypi there is cystitis of moderate severity. 

Medullary sarcoma may be characterized by urine of green- 
ish-brown color and putrid odor. In later stages there may 
be a severe cystitis. 

In epithelioma we find a moderate or sometimes severe 
cystitis. In the sediment there are present blood, pus, small, 
round or oval epithelial cells, sometimes caudate cells with 



MALIGNANT GROWTHS. 467 

two or three small projections, their nuclei large and brightly 
glistening, with several in the same cell. Sometimes ten or 
twelve cells may be found together, forming a shred. 

In villous or vascular tumors the urine is normal in quan- 
tity, red-brown to brown-black in color, feebly-acid reaction, 
but alkaline when tumor grows rapidly; the sediment is fine, 
Hocculent, brownish in color, with reddish or large shreds ; 
the urine is usually normal in consistence, but at times stiffens 
suddenly to a jelly-like mass ; after long shaking, again be- 
comes liquid and of slightly reddish-yellow color. Some- 
times there are severe symptoms on micturition. 

In one case of carcinoma the writer found twenty per cent, 
of albumin by bulk in the urine without blood or pus to ac- 
count for it and no casts. 

Physical Examination. — When there is no prostatic hy- 
pertrophy, the finger in the rectum may detect an area of in- 
duration in the case of malignant growths, and a sense of in- 
creased resistance. The bladder should be nearly or quite 
empty. 

The cystoscope is another means for detection. If for any 
reason it cannot be used, digital exploration of the bladder by 
way of the perinseum is the last measure at our command. 

According to Wathen, when we inspect the bladder with 
the cystoscope, we may encounter two well-marked varieties 
of vesical tumors — the villus-covered and the bald. The villus 
papilloma may be malignant or benign, but the bald is always 
malignant, and particularly so if the patient is over forty-five 
years of age. The villus papilloma resembles chorionic villi, 
which are of a light fawn color, showing beautifully the cap- 
illary circulation. They float about in the urine, and re- 
semble sea-weeds under the water. Their attachment to the 
bladder wall is always outside the trigonal area, to the outer 
side of the orifice of the ureter, and more often in front of it, 
while sometimes they arise from the true lip of the ureter it- 
self, and thus have probably been caused by some direct irri- 



468 DISEASES OF THE BLADDER. 

tation of an unusual kind from the urine of the kidney on 
that side. 

The pedicle of this variety of tumor varies in size from a 
mere thread to that of a quill, and the larger the pedicle, or 
base, the more liable it is to become malignant. The multi- 
plicity of villus papilloma also tends toward malignancy. 

The benign papilloma is very liable to undergo a gradual 
malignant transformation of the stalk or pedicle. The villus 
malignant papilloma or carcinoma is less liable to be single, 
and occasionally a certain proportion are partly free from villi, 
and approach the bald type. These have a large base or 
pedicle, and show a tendency toward infiltrating the bladder 
wall. They are more often situated on the right side near 
the orifice of the ureter, and the first symptoms of hsematuria 
occur usually between forty-five and sixty years, while the 
benign appear earlier. The bald is the most malignant of the 
bladder tumors, and differs from the two preceding forms in 
that it tends to involve the bladder wall, is not so prominent 
on the surface, and the rapidity with which other vesical symp- 
toms appear — as cystitis, pain, etc., after the initial haemor- 
rhage. These tumors also appear near the ureters, and pre- 
sent a bald, irregular, nodular growth of a dull red color 
similar to that inside the mouth. It is in strong contrast to 
the white color of the posterior wall. 

Differential Diagnosis. — Benign growths are to be differ- 
entiated from malignant growths as follows : If the area of in- 
duration can be felt by the finger in the rectum, if the patient 
be over 50 years of age, and if the cystoscope shows a growth 
with an ulcerated surface having irregular, ragged, everted 
and cedematous edges, and if pain is a marked symptom, the 
chances are strongly in favor of the disease being malignant. 

Examination of the blood should be made in doubtful cases. 

According to Wathen, pain is a more prominent symptom 
in the bald type of tumor, and the extent of involvement of 
the bladder is better told by the extension of the pain than 
by the hardness of the vesical wall. 



MALIGNANT GROWTHS. 469 

In summing up the points of differential diagnosis of 
tumors of the bladder, the following are the principal facts to 
consider : The benign villus appears between thirty and forty- 
five ; the initial haemorrhage is rarely severe, fragments are 
often evacuated, and the prognosis as regards length of life is 
good. 

The malignant villus appears between fifty and sixty, 
haemorrhage is very rarely severe, fragments evacuated are 
common, and the average life is about eight years. 

The bald malignant appears between fifty-five and sixty- 
five, haemorrhage is commonly severe, fragments are rarely 
evacuated, and the average life is a little over two years. 
The softer tumors have longer periods of haemorrhage, while 
the denser ones exert their energy in infiltrating the vesical 
wall. 

" Most tumors, whether benign or malignant, terminate the 
existence of the patient by inducing renal complications." 
(Fen wick.) 

The larger and thicker the stem or pedicle of the tumor, 
the more malignant it is liable to be and the sooner will result 
infiltration of the bladder wall, followed by irritability, pain, 
cystitis, pyonephrosis, and death. 

Effects. — Compression of the ureters by the tumor may 
lead to hydronephrosis, pyelonephritis, pyonephrosis and 
septicaemia. Rupture and uncontrollable haemorrhage may 
result. 

Course and Prognosis. — Bladder-growths progress slowly. 
The average duration is from three to seven years, but the 
patient may, in exceptional cases, die in a few months, from 
frequent and repeated haemorrhages or from cystitis and ne- 
phritis superadded. 

Death is the inevitable result of bladder-tumors when left 
to thernselves. 

In carcinoma of the bladder death may take place in a year 
from exhaustion, urinary septicaemia, rupture or uncontrollable 
haemorrhage. 



470 DISEASES OF THE BLADDER. 

Supra-pubic incision and drainage early may prolong life 
and relieve pain. 

Prognosis after Operation. — Thompson reports forty-one 
cases. In seven papillomatous cases there was no reappearance 
of symptoms in from three to ten years. In fifteen other cases 
death took place ; ten were malignant, two papillomatous, 
and the rest myomatous, with suspicious nuclei. Nineteen 
others lived from a year to a little less than four years after 
operation. 

Watson has collected statistics of eleven others, three of 
whom died in from six months to two years, one showed re- 
currence in from two to five years, one showed no evidence of 
recurrence in four years, one none in five, and in one the result 
was not stated. 

In sarcoma the statistics of Hinterstoisser show the follow- 
ing : Of twenty-one cases twelve died, six recovered, three 
were nnrecorded. The longest period without recurrence 
which Watson has recorded is that of five years. • 

Fenwick reports 135 operations out of 500 cases with only 
five deaths due to operation. 

Treatment. — In cases where operation cannot be performed 
vesical irrigations of Silver nitrate, one grain to one drachm 
of distilled water acidulated with a little Nitric acid, are en- 
dorsed by Carleton in the following manner : 

In the first irrigation half a drachm of the solution is added 
to four ounces of warm water, the strength being gradually 
increased every day or two until one or even two drachms are 
employed, regulating it so that no pain, increased frequency 
of micturition or straining follows the irrigation. Occasion- 
ally, when the solution of maximum strength has been in 
daily use for a considerable period, the bladder becomes irri- 
table, and a weaker solution must be employed, but the treat- 
ment should not be discontinued. About two ounces of the 
selected solution should be introduced into the bladder, re- 
tained for a few seconds, then allowed to discharge itself 



MALIGNANT GROWTHS. 471 

through the catheter while the syringe is being refilled. The 
douching must be repeated daily and continued without inter- 
mission for four, five or six months, reaching the maximum 
strength of solution some five, six or more weeks from the 
commencement of the treatment. If bleeding has ceased, as 
it should, the irrigation must be continued every other day 
for six months or longer, and afterwards every third day for a 
variable period. After this long course of treatment the ap- 
plication may be discontinued, even for a year, without any 
symptoms recurring ; but should blood re-appear in the urine 
the daily douching — commencing with the minimum strength 
and gradually increasing — must be again resorted to. In this 
way hsematuria, as well as the growth, may be permanently 
controlled, and the patient may live in comfort for many 
years. The treatment, at the start, may occasionally increase 
the haemorrhage, but after several applications the blood 
lessens in quantity and finally disappears. Sometimes it 
never entirely ceases, being especially noticeable in small 
quantities at the time of catheterization, though every precau- 
tion may have been taken in introducing the instrument. It 
is apparently caused by the catheter damaging a growth situ- 
ated near the neck of the bladder. In such a case, when the 
treatment is discontinued the haemorrhage ceases, and the 
after-effect may be quite satisfactory. (Uropoietic Diseases, 
second edition.) 

To check haematuria, which is sometimes exhausting and 
dangerous, Francis Watson advises long-continued irrigations 
of the bladder through a soft rubber catheter with very hot 
water, no° to 120 F. The use of strong astringents and of 
styptics within the bladder cannot be advised, as they are 
liable to produce tough coagula. 

In cases where the coagula have formed, it is wiser to allay 
tenesmus and pain with Opium than to attempt to remove the 
clots. The pressure caused by the filling up of the bladder 
tends to check the haemorrhage after a time, and in a few 



472 DISEASES OF THE BLADDER. 

hours the clots will disintegrate and pass away. If the pa- 
tient's general condition is bad, and the flow of urine and 
blood distend the bladder to a dangerous degree, attempt may 
be made to break up the clots and wash them out with large 
catheters or evacuators. 

Adrenalin chloride solution internally is used, together 
with washing out the bladder, to stop the haemorrhage with 
good results, but it will not always stop the haemorrhage en- 
tirely. The use of normal salt solution in cases of collapse 
should not be forgotten. The following precautions should 
be observed : 

The most important indication in the use of infusion into 
the vein is that the temperature of the fluid should be equal 
to that of the blood or above. If the temperature is below 
ioo° shock may be distinctly increased. The infusion into 
the vein, as ordinarily given, is much below the temperature 
that it should be. If a metal 01 glass tube is inserted into 
the vein it of necessity cannot be very large ; the flow of fluid 
through the rubber tube of the syringe cools it very rapidly, 
so that with ordinary room temperature, if the fluid in the 
bag has a temperature of 105 , it actually enters the circula- 
tion of the patient at about 90 . This can be obviated by 
using one of the mechanical arrangements for warming the 
fluid while in the bag, and also while it is in the tube. If an 
ordinary rubber tube is employed it may be surrounded with 
gauze saturated with hot water. 

Under no circumstances should an infusion be made di- 
rectly into a vein unless there has been a loss of blood. If 
the symptoms of shock are not accompanied by haemorrhage 
the injection of the hot normal salt solution should be into 
the colon or into the subcutaneous cellular tissue. The in- 
jection of the colon is probably the most efficient, but here 
the temperature should be 115 . {Therapeutic Gazette.) 

In the treatment of toxaemia saline solution will unques- 
tionably play a most important role in the future. If the 



MALIGNANT GROWTHS. 473 

fluid is injected into a vein the same rule should be followed, 
that there must be an extraction of blood. In cases of gen- 
eral sepsis, pneumonia, uraemia and other toxaemic states, pre- 
ceding the injection, there should be a free bleeding of the 
patient. If the blood is not removed, resort must be had to 
the hypodermic or the colonic injection. 

In cases of emergency an approximately accurate solution 
can be prepared by adding a teaspoonful of table salt to a 
pint of water. A much more accurate formula, and one which 
more nearly represents the saline constituents of the blood, is 
that proposed by Dr. H. A. Hare, which is composed of the 
following ingredients : 

Calcium chloride, 0.25 gramme; 
Potassium chloride, 0.10 gramme; 
Sodium chloride, 0.9 gramme; 
Sterilized water, 1000 cc. 

Surgical Treatment. — In benign growths removal should 
be undertaken at the earliest possible moment, unless the pa- 
tient be exhausted, or renal disease or other complicating 
malady contra-indicate operation. 

In malignant growths the decision as to operation depends 
upon the amount of pain or haemorrhage present. Operation 
as a palliative measure may be required in cases of extreme 
pain or haemorrhage. 

In certain cases of cancer in which the growth is of limited 
extent, and situated at or near the summit of the bladder, re- 
section is occasionally successful. 

According to Wathen in regard to the operative interfer- 
ence with vesical growths we should be guided by the extent 
and character of the tumor. When the bladder wall has been 
infiltrated, so as to be felt per rectum, we should not attempt 
to remove the tumor unless we remove the entire bladder, 
and if this is impracticable we may substitute a supra-pubic 
incision to relieve the pain and for better drainage. Most 
operators condemn the perineal route in this condition, as it 



474 DISEASES OF THE BLADDER. 

increases the pain and vesical spasm, and Fen wick says that 
" Perineal cystotomy for a radical attack on vesical tumors 
does not deserve the name or cloak of surgery." 

When we have a single villus-covered pedunculated tumor, 
with unilateral renal pain, or causing an obstruction of the 
urethra, we should make a small supra-pubic incision and 
remove the growth. 

PARASITES AND OTHER FOREIGN BODIES. 

Animal parasites are the Distoma, the Filaria and the Echi- 
nococcus. Cysts of echinococcus may be found free in the 
bladder. The distoma may apparently cause a fungoid tumor. 
The ova may be found in the urine. In cases of fistula, oxy- 
uris and ascaris may enter the bladder. 

Bacteria, yeasts and the thrush-fungus have been found in 
the urine in the bladder, the two last more commonly in dia- 
betes mellitus. The thrush-fungus (Oidium albicans) may 
cause a white deposit on the mucous membrane. 

L/eptothrix may be present in the bladder, and the fine, 
hair-like particles be present in the urine. Sarcinse are also 
found. 

Bacteriuria, the voiding of bacteria in fresh urine, is fre- 
quently observed ; the urine may then have the odor of stale 
meat-broth. Salol in fifteen-grain doses every two hours is 
the best remedy, but should be discontinued or lessened in 
amount if the urine darkens during administration of the 
agent. 

Among other foreign bodies found in the bladder are frag- 
ments of catheters, hair-pins, pipe-stems, spicules of bones, 
bullets, etc. 

These objects may serve as a nucleus for stone formation. 
In cases of vesico-intestinal fistula, striped muscular fibres, 
vegetable cells and food may be found in the urine. Flatus 
into the bladder may be observed in such cases. Gall-stones 
have been found in the bladder. 



STONE IN THE BLADDER. 475 

Hair from dermoid or ovarian cysts, bits of cartilage, bone 
and even teeth may be passed from trie bladder into the urine. 

STONE IN THE BLADDER. 

Synonyms. — Vesical calculus. 

Etiology. — For the formation of stone in the bladder two 
conditions are essential : 

i. A tendency toward deposit of the urinary solids from 
solution in the urine. 

2. A local disposition for the solids thus deposited to adhere 
to a nucleits or matrix. 

The nucleus is usually organic — an albuminous or mucin- 
ous coagulum derived from the mucous membrane. In the 
bladder, however, an aggregation of uric acid crystals, deposit- 
ing originally in the kidney and passing into the bladder, or 
in some ten per cent, of the cases extraneous substances, as 
blood-clots, altered ropy pus mixed with precipitated phos- 
phates, or aggregations of crystals of oxalate of calcium from 
the kidneys, may serve as a nucleus. Urate and oxalate stones 
from the kidneys are likely to be crusted with phosphatic 
material in the bladder. 

Classification. — Calculi in the bladder may be divided into 
three classes, as follows : 

i. Those formed from normal constituents of urine : uric 
acid, urates, phosphates and mixed calculi of uric acid or 
urates coated with phosphates. 

2. Those formed from normal constituents, but not depos- 
ited in normal urine : oxalate and carbonates. 

3. Those formed from substances entirely foreign to normal 
urine : indigo, xanthin, cystin. 

Physical Characteristics of Calculi. — Vesical calculi are 
usually solitary, but cases are known to the writer in which a 
number have occurred, with the result that the crushing op- 
eration resulted fatally in one case. 



476 DISEASES OF THE BLADDER. 

They vary in size from that of a large pea to a magnitude 
limited only by the capacity of the bladder. The hardest 
stones are likely to be solitary, namely, the uric acid and the 
oxalate. 

As a rule, they are rough from crystalline deposits, but cases 
occur in which they are smooth. 

The average size is from one to two inches and the weight 
from two drachms to one ounce. The shape of single stones 
is usually a flattened oval ; a multiplicity of them produces a 
flattening of opposing surfaces. The oxalate stone is the 
hardest and the phosphatic the softest. They may be either 
homogeneous in composition or consist of alternating layers 
of different substances. 

Uric acid stones are multiple, small, hard, gray-yellow or 
reddish-brown. If smooth, they cause but slight cystitis. 

Urate calculi are often encrusted with oxalate or phosphate. 
They are common in the region about Chicago. 

Phosphatic calculi are dirty-white, and soft, and crumbling. 

Oxalate calculi are hard, brownish, spheroidal, nodular, of 
medium size, and usually of renal origin ; they are not rarely 
coated with phosphate, and occasion much cystitis, with 
haemorrhage. 

Calcium carbonate stones are multiple, very small, white 
and hard. 

Cystin calculi are small, waxy, yellowish, translucent and 
turn green on exposure to the air. 

Xanthin calculi are very rare ; they are smooth and of a 
red-yellow color. 

Indigo seldom occurs except in association with some other 
material. 

Biliary calculi may be found in the bladder in cases of 
fistula. 

Situation. — Most of the stones are found in the lowest part 
of the bladder (bas-fond); they may also be present in the 
neck, above the pubis, and behind the prostate. They may 
be either free or encysted. 



STONE IN THE BLADDER. 477 

Conditions Favoring the Formation of Stone. — Among 
these may be mentioned the following : 

i. Diseases of the brain or spinal cord (paralysis of the 
bladder.) 

2. Free use of animal food and malt liquors coincidently 
with excessive fatigue and profuse sweating. 

3. Presence of foreign bodies introduced into the bladder 
from without. 

4. Retention of urine from any cause. 

Clinically, whenever we find residual urine we expect 
sooner or later to find stone in the bladder. That stone may 
form rapidly, i. e. within a few weeks, there is good reason to 
believe. 

In one interesting case which the writer saw, that of a girl 
about ten years of age, a hair-pin served as a nucleus for an 
enormous phosphatic stone. 

Etiological factors in the stone formation are supposed to 
be the drinking of limestone water, diet, hereditary predis- 
position, race, etc. 

Occurrence. — Stone in the bladder occurs from fcetal life to 
old age. 

By far the larger number of cases occur in those under 
twenty. The writer, however, sees quite a number of cases 
in elderly men with long-standing cases of cystitis. 

Many cases occur in children. 

It is about thirty times as common in men as in women. 
Negroes are less subject -to this disorder than the other races. 
It seems to be more common in certain localities than others. 
The writer's attention has been called to the comparative in- 
frequency of calculous diseases in Savannah, Georgia, and to 
the frequency in the region around Chicago. Stone in the 
bladder is said to be infrequent in New England, but not un- 
common in Ohio, Kentucky, Tennessee, North Carolina and 
Alabama. In Europe the same tendency to calculous disease 
exists in certain localities. 



478 DISEASES OF THE BLADDER. 

In India there are an enormous number of cases of this dis- 
ease. 

Children are more liable to uric acid calculi and old persons 
to phosphatic. 

Pathologic Anatomy. — The muscular coat of the bladder 
becomes gradually hypertrophied from increased use, and its 
interlacing fibres begin to stand out in relief. A tendency to 
habitual contraction is established, due to irritation and in- 
tolerance of distention. The lining membrane of the bladder 
loses its normal salmon-pink color and becomes deep red, 
granular, or even villous, with occasional ecchymosis, and 
sometimes patches of yellowish surface-exudation. The 
bladder walls are thickened materially by the exudation also 
taking place in the submucous web of connective tissue 
around the enlarged follicles. 

Diagnosis and Clinical Features. — The classical symptoms 
of stone in the bladder are the following : 

Pain along the urethra, at end of penis, in the testicles or 
down the thighs. 

Sudden stoppage of the stream (caused by the carrying of 
the stone by the flow of urine to the outlet of the bladder), 
accompanied by a twinge of sharp pain shooting along the 
course of the urethra and felt most acutely at the meatus. 

Frequency of urination. Both pain and frequency are 
worse on motion. 

Stone may, however, be present in the bladder without giv- 
ing evidence of its presence during life. 

Misplaced sensations are sometimes caused by the chronic 
cystitis of stone, the usual kind of pain being absent. 

Children with stone habitually pull upon the prepuce, and, 
in general, the calculous patient habitually squeezes and rubs 
the under surface of the glans penis, just behind the fraenum. 

Rest upon the back, with the hips raised, relieves the pain 
of stone. 

Uneasy sensations and sometimes acute pain are felt in the 



STONE IN THE BLADDER. 479 

rectum ; more or less dull pain above the pubes, radiating to 
the hips, sacrum, thighs and perinseum. 

In a few cases calculi have been known to work their way 
out of the bladder through ulcerations involving all its coats. 

The Urine in Stone in Bladder. — The urine is that of 
gradual inflammation of the bladder. At first, increase of 
mucus and epithelial debris, with deposits of crystals and a 
slight hsematuria after rough or violent exercise or a jolting 
ride. Later, the urine of cystitis, with deposit of crystals 
and blood at the close of micturition, the hsematuria being 
worse after motion. 

In severe cases the urine may be very foul and tinged with 
blood, the pus sediment being surmounted by a layer of blood. 
Albumin may be abundant and the symptoms (severe chills, 
fever and prostration) suggest presence of pyelonephritis. 

Diagnosis. — Stone being suspected from the symptoms and 
condition of the urine, the diagnosis is confirmed by sound- 
ing, the use of the cystoscope, or the X-ray apparatus. 

The Roentgen ray very clearly showed stones present in one 
of the writer's cases, in which Dr. Adams operated and re- 
moved five stones, weighing in all ioo grains. 

Prognosis. — The prognosis in vesical calculus depends es- 
sentially upon the general condition of the patient, his ability 
to undergo operation, and the kind of operation which is 
possible or necessary. 

Effects. — These, in addition to the clinical features de- 
scribed, are hypertrophy of the bladder, pyelitis and pyelone- 
phritis. 

Dangers and Complications in Cases of Stone in the Blad- 
der. — Abscess formation in the bladder and prostate ; outside 
of the bladder, in the neighborhood of the neck, from peri- 
cystitis, and pelvic cellulitis, terminating in abscess ; in chil- 
dren both acute and chronic peritonitis, due to operations for 
relief. 

The usual cause of death, when the patient is not relieved 
by operation, is pyelonephritis. 



480 DISEASES OF THE BLADDER. 

The association of malignant disease and stone is possible 
and should always be suspected if there is in addition to the 
symptoms of stone progressive loss of flesh in an elderly patient, 
and especially if there is much hsematuria. The latter, how- 
ever, may not be marked, even in cases where both stone and 
cancer occur together in the early stage of the latter. 

Treatment. — Preventive treatment of stone has been con- 
sidered under Lithuria, Phosphaturia, and Oxaluria. 

Palliative treatment in cases not fit for operation consists 
of rest, milk diet, remedies previously considered under 
Cystitis for relief of pain, and, in the case of uric-acid stone, 
alkaline waters, Borocitrate of Magnesia in io-grain doses 
two hours after a meal ; in phosphatic stone the remedies al- 
ready mentioned under Phosphaturia. 

Surgical treatment consists in removal of the stone either 
by the crushing or by the supra-pubic method. In this 
country the latter is chiefly used. In India the crushing 
operation is done on an enormous scale, many surgeons hav- 
ing used it more than five hundred times. Baker, of Hydera- 
bad, reports 1,734 operations of lithotrity with a mortality 
of a little over one per cent. ! 

To prepare the patient for operation give Salol in five-grain 
doses, every three or four hours, until the urine is free from 
offensive odor. If the Salol causes darkening of the urine, it 
is to be given less frequently. 

The early diagnosis and removal of stone is advisable be- 
fore complications occur. 

Wounds. — These may be from sharp instruments or ob- 
jects, firearms and falls, especially upon the perinaeum. 
Pressure of the child's head, as in prolonged labor, may 
wound the bladder. If the peritoneal part is injured extrava- 
sation of urine takes place, quickly followed by septic peri- 
tonitis ; in rare cases, however, the urine may become en- 
cysted. Surgical wounds usually heal if properly attended 
to. Contused wounds are a dangerous injury. The treatment 
is wholly surgical. 



STONE IN THE BLADDER. 481 

Rupture.— In rare cases over-distention has been known to 
burst the bladder, as in alcoholism. It may be due also to 
fracture of the pelvis, blows, excessive straining, injections or 
tumors. Rupture of the bladder occurs much more frequently 
in men than in women, and usually between the twelfth and 
fiftieth year. The symptoms are intense pain, a feeling as if 
something had broken or given way, followed by vomiting, 
faintness or collapse, and the symptoms of shock. A small 
amount of bloody urine is obtained by use of the catheter. 
The prognosis is unfavorable unless prompt surgical treat- 
ment is to be had. 

Supra-Pubic Cystotomy. — The indications for this opera- 
tion are the following : 

i. Calculi and foreign bodies. 

2. Tumors. 

3. Tuberculosis. 

4. Vesical haemorrhage. 

5. Rupture. 

6. Prostatectomy (certain cases). 

7. For forming a fistula. 

8. Severe cystitis. 

9. As a preliminary operation in performing retrograde 
catheterization. 

The operation is performed by different methods according 
to the necessities of a given case. 



3 1 



CHAPTER XVII. 



DISEASES OF THE PROSTATE. 



The conditions to be considered are malformations, atrophy, 
hypertrophy, congestion, inflammation, tuberculosis, tumor, 
cysts and calculi. 

Malformations. — Unless there is some grave malformation 
of the genital tract, absence of the prostate is seldom noticed, 
but hyperplasia or congenital smallness may be present. 

Atrophy. — This may be due to pressure of tumors in 
neighboring parts; it is also not unusual in old age. 

HYPERTROPHY OE THE PROSTATE. 

Etiology. — The etiology of enlarged prostate has not been 
satisfactorily determined. Some degree of enlargement is 
found in about thirty per cent, of men who have passed the 
fiftieth year. 

Different writers state its frequency differently. Riesman 
concludes that it is present in one out of three men who are 
past sixty. It may occur, however, much earlier in life. In 
extreme old age it is rare. 

There is some connection between the process and the tes- 
ticles, and it is probable that some alteration in. the function 
of the latter may lead to enlargement of the prostate in old 
age. It is known that removal of the testicles quickly leads 
to atrophy of the prostate within a few days after the opera- 
tion. Vasectomy, division of the vas deferens, produces the 
same result, though in a less marked degree. 

Pathologic Anatomy. — The prostate reaches the maximum 
of its normal growth at about the fortieth year of life, when 



HYPERTROPHY OF THE PROSTATE. 



483 



it measures four to four and one-half cm. in width and two to 
two and one-half cm. in thickness, weighing sixteen to seven- 
teen grammes. The hypertrophied prostate weighs from 
twenty-three to eighty-five grammes on an average, the larg- 
est known weighing two hundred and eighty-eight. The en- 
largement may involve one or both of the lateral lobes, the 




Fig. 30. — Section of bladder and prostate; the former hypertrophied, the latter forming 
prominent tumors within the bladder. — (From Thompson.) 



so-called median lobe, or all three together. At the same 
time there is a characteristic change in the shape and width 
of the posterior urethra, into the lumen of which the median 
lobe often projects as a rounded hemispheric tumor, causing 
obstruction, or valve-like folds may be occasionally produced 
in the mucous membrane by the enlargement. 

Section of the prostate shows it firm, whitish and dotted 
with brownish points — "grains of snuff" so-called. There is 
frequently a bulging of rounded masses which can be readily 
shelled out. (Riesman.) 



484 DISEASES OF THE PROSTATE. 

The hypertrophied prostate presents a deformity as well as 
an enlargement, due to distinct tumors projecting toward or 
into the bladder and urethra. 

Pathologic Histology. — Prostatic hypertrophy consists in 
an overgrowth of all the normal elements — fibrous, muscular 
and glandular — the first two predominating. In addition to 
uniform enlargement there is a tendency on the part of the 
first two elements to arrangement into distinct nodules of 
spherical form. 

Usually section shows an abundance of stroma of muscular 
and connective tissue cells, with atrophy of the glands, the 
tubules having a low epithelial lining and a dilated lumen in 
which detached epithelia, detritus, and amylaceous bodies are 
found. In certain cases adenoma is suggested by marked 
glandular hyperplasia ; in others, liomyoma, like that of the 
uterus, by predominance of non-striped muscular tissue. 

Diagnosis. — The finger in the rectum encounters a rounded, 
dense mass, either smooth and symmetrical or variously dis- 
torted and nodulated. The normal prostate is a soft, chestnut- 
like body, hardly recognizable except by the skilled touch. 

Clinical Features. — In the earlier stages we find the fol- 
lowing : 

i. Difficulty in starting the flow of urine. 

2. Feebleness of the stream. 

3. Frequency of urination at night (due to venous conges- 
tion of the vesical neck). 

4. Polyuria. 

Later, when cystitis is established, we find : 

1. Frequency of urination both by day and night. 

2. Absence of feeling of satisfaction after urination. 

3. Dull pain along the urethra. 

4. Dribbling of urine, due to increase in quantity of the 
residual and overtaxing the sphincter. 

The Urine. — In the earlier stages we find polyuria with 
urine of low specific gravity, and perhaps a trace of albumin. 



HYPERTROPHY OF THE PROSTATE. 



485 



As much as six or eight pints may be passed in a day, and the 
case may be pronounced diabetes insipidus. 

When vesical catarrh appears we have the urine of chronic 
cystitis of varying degrees of severity. 

Differential Diagnosis. — Hypertrophy of the prostate is to 
be differentiated from cancer of the prostate, tubercle of the 
prostate, urethral stricture, vesical calculus and tuberculosis, 
tumor of the bladder, renal calculus and tuberculosis. The 
leading diagnostic features of these disorders have already 
been given. 




Fig. 31. — Section of bladder and prostate, showing marked but not great enlargement 
of lateral lobes and median portion. — (From Thompson.) 



Course. — The disorder, as a rule, pursues a slow course, re- 
maining, so far as the cystitis goes, mild for weeks or months, 
again increasing to an acuteness which confines the patient to 
bed. Retention of urine finally takes place in many cases, 
and the patient resoits to the catheter for the balance of his 
life or undergoes an operation. 

Effects of the Enlargement. — The morbid conditions which 
result are the following : 



486 DISEASES OF THE PROSTATE. 

Distortion of the prostatic urethra. 

Elevation of the level at the vesico-urethral orifice. 

Obstructions to the return of blood from the bladder. 

As a result of these conditions a number of others sooner 
or later occur : dilatation of the bladder with increase of re- 
sidual urine, hypertrophy of this organ and diverticula; dilata- 
tion of the ureters and renal pelves, with stagnation of urine, 
congestion and catarrhal inflammation of the entire urinary 
tract, tendency to calculus formation, pyelonephritis, and 
death from uraemia. 

Prognosis. — This depends on the results of catheterization. 

The essentials on which to base an opinion are the follow- 
ing : 

i. The condition of the kidneys. 

2. The condition of the arteries. 

3. The general nutrition of the patient : weight, flesh, 
vigor, condition of the skin, digestion, excretion, occupation, 
and habits. 

In a patient otherwise in good condition the catheter may 
be used successfully and comfortably for ten or fifteen years 
or more. 

Cause of Death. — In a patient with polyuria, more or less 
albuminuria and cylindruria, indicating a low grade ureteritis 
and pyelitis, uraemia is not an uncommon cause of death, 
supervening after taking cold, or from over-exertion or im- 
prudence in diet. 

The symptoms of uraemia in such cases are as follows : 

1. Hot, dry skin. 

2. Loss of appetite. 

3. Sleeplessness and restlessness. 

4. Dry, red, or pasty tongue and parched mouth. , 

5. Depression, headache, and wandering of the mind. 

6. Constipation. 

Polyuria, with more albumin than the pus accounts for 
suggests renal disease, demands a guarded prognosis, and re- 
quires caution in treatment. 



HYPERTROPHY OF THE PROSTATE. 487 

Hard and tortuous arteries with polyuria and cardiac 
hypertrophy are a serious coincidence, and in such cases the 
prognosis is bad as to time. 

Treatment. — Removal of the cause by operative measures 
before retention from obstruction takes place is a principle of 
modern surgery. When for any reason such measures cannot 
be taken the essentials of treatment are as follows : 

i. A nutritious dietary free from articles which irritate the 
prostate, especially beer and champagne. 

2. Warm clothing and avoidance of cold or wet seats. 

3. Warm baths, best taken at bed-time. 

4. Regular urination in the' upright position. 

5. Careful attention to the bowels. 

6. Relief from pain by remedies and suppositories. 

7. Carefully regulated exercise in the open air. 

8. Pursuit of vocation. 

9. Avoidance of sexual excitement. 

10. Catheterism for residual urine. 

11. Medical and surgical treatment for cystitis and haemor- 
rhage, if either or both exist. 

The patient should not take too great an amount of fluids, 
and none at all in the latter part of the evening before bed- 
time. 

The patient should be instructed to pass his water at regu- 
lar intervals, and when obliged to urinate during the night 
lie should rise from his bed and pass his urine in the upright 
position. 

In clothing the patient, woolens, flannel abdominal binders, 
and thick- soled shoes with cork inner soles may prove ser- 
viceable. The patient should in general be well protected 
against cold and dampness, and when possible should be made 
comfortable with the dry warmth of an open fire. 

For the liver the fluid extract of Taraxacum has been 
found by the writer to be of great utility in these cases. It 
may be used, as suggested by Dr. Spach, in combination 



488 DISEASES OF THE PROSTATE. 

with Chimaphila and Corn-silk ; the formula is given below. 
Freyer thinks nothing is better for catharsis in enlarged pros- 
tate than confection of Sulphur or Senna, or equal parts of 
both. Alum, Licorice powder, the Sulphate of Soda, or one 
of the natural bitter waters, like Hunyadi or Hathorn, may 
be taken in the morning. If these fail to induce a daily 
bowel movement, enemata should be administered in the 
morning after breakfast. As the patient goes to stool he 
should throw into the rectum, just above the anus, a small in- 
jection of one drachm, half glycerine and half water. The 
syringe best suited for this purpose is a hard-rubber urethral 
syringe, with a nozzle an inch long. This will usually act 
immediately, producing a satisfactory and easily voided stool, 
without the unnecessary prostatic irritation which may attend 
the use of a large enema. 

Sitppositories for the relief of painful frequency may be 
mentioned as follows : 

No. I. 

Iodoform, gr. xii. 

Extract of Hyoscyamus, gr. viii. 

Cocoa butter, to make 8 suppositories. 
Use one every three or four hours. 

No. 2. 

Lupulin, 3j. 

Mono-bromide of Camphor, 3J- 

Cocoa butter to make 12 suppositories. 

No. 3. 

Aristol, gr. xl. 

Alcoholic extract of Belladonna, gr. ijss. 

Cocoa butter q. s., 10 suppositories. 

In cases where there is severe pain which does not yield to 
the above, Laudanum or Morphine suppositories may be ne- 
cessary, and sometimes Opium internally. It is well, how- 
ever, not to give or use Belladonna in any form as long as the 
bladder retains any expulsive power ; No. 2 of the above or 
Morphine suppositories are better in such cases. 



HYPERTROPHY OF THE PROSTATE. 489 

The best exercise is walking or carriage riding, but one of 
the writer's patients insisted that horseback riding made him 
feel better than any other form of exercise, This, however, 
was probably due to the fact that he had been accustomed to 
daily rides for years. In order to keep the mind occupied the 
patient should pursue as far as possible his regular vocation. 

The catheter should be employed, according to Freyen 
when in elderly men there is difficulty and frequency of mic- 
turition with some pain, the urine being turbid, possibly 
fetid, the patient looking ill and worn-out, and the hypogas- 
tric dullness pointing to the presence of a considerable quan- 
tity of residual urine. The employment of the catheter for 
the first time in these cases may be attended by severe consti- 
tutional disturbances. The examination should be made in a 
warm room, and the patient should be put to bed, and if con- 
stitutional disturbances set in, he should remain there longer 
than two or three days. The urine should be drawn off grad- 
ually, the bladder not being completely emptied for two or 
three days. 

In an advanced state of prostatic disease of this kind the 
urine, even when clear and acid on the first introduction of 
the catheter, generally becomes cloudy and finally ammoni- 
acal in the course of a few days, and constitutional symptoms 
supervene. A rigor will probably occur, or the temperature 
may rise to 103 ° or 104 F., profuse perspiration setting in. 
The normal temperature being reached, the fever may not re- 
cur. Sometimes more than one attack of this kind occurs, or 
the fever may continue for some days, gradually subsiding ; 
but occasionally the patient sinks into a low typhoid state. 
If the kidneys are much affected, uraemia may set in, followed 
by coma, and may result in a fatal termination. The fever is 
termed "urinary," "urethral" and "catheter," but its exact 
cause is unknown. Its treatment is similar to that following 
instrumentation or operation for stricture of the urethra. (See 
Urinary Fever.) 



490 



DISEASES OF THE PROSTATE. 



According to Freyer, habitual catheterization must be em- 
ployed when the residual urine amounts to between three and 
four ounces. The catheter should be passed once in twenty- 
four hours if the urine amounts to four ounces or less, the 
best time being at bedtime. It should be used twice daily if 
six ounces are retained ; three or four times daily if eight or 
ten ounces are retained. The catheter, when power of vol- 
untary micturition is lost, should be used generally every four 
hours. In all cases the urine should be drawn off before pain 
or marked discomfort is felt, otherwise congestion of the pros- 
tate and bladder resulting in cystitis will be produced. 

If, however, a patient has not more than from two to four 
ounces of residual urine, which is sterile, which is passed 
without pain or undue discomfort, which also does not get 
him up more than once a night, catheterization may well give 
place to internal treatment directed toward making the urine 
antiseptic, and to increasing the general circulatory tone. Of 
the drugs useful for this purpose, Salol, Urotropin, Ergot, 
Strophanthus, Sandalwood oil and Saw Palmetto are most 
serviceable. For increased frequency of urination Hyoscya- 
mine sulphate will be found useful. When the retention 
reaches such a degree that the bladder is distinctly distended, 
even after micturition, which can be detected by a bimanual 
examination, a finger of the right hand being introduced into 
the rectum, while the left hand presses into the supra-pubic 
region, intermittent catheterization is absolutely indicated, 
even though the frequency of micturition is not so great as to 
be harassing. Under these circumstances a soft-rubber cath- 
eter is the instrument of choice. {Therapeutic Gazette?) 

The patient should be taught the use of the catheter. The 
best instrument for habitual employment is a soft coudee, No. 
7 to 9 E. It should be used by the patient while standing, 
unless he is very infirm. 

The catheter having been introduced as far as the com- 
pressor urethrse muscle, the whole anterior urethra should be 



HYPERTROPHY OF THE PROSTATE. 491 

flushed out with a mild antiseptic solution, preferably Boric 
acid, a drachm to the pint, by means of a fountain syringe. 
The nozzle of the syringe is introduced into the free end of 
the catheter. After this flushing, the catheter should be 
passed into the bladder. It is held perpendicularly while its 
end is introduced into the urethra, is then gradually depressed 
into the horizontal position as it glides along the canal over 
the obstruction and into the bladder, the curved end being 
directed upward toward the roof of the urethra. When the 
middle lobe is much enlarged, a bicoudee catheter or a well 
curved one terminating in an elbow may be necessary to over- 
come the obstruction. 

This draining of the bladder should be practiced once or 
twice a day, until the patient is able to void urine every two 
or three hours. When he is unable to void urine, or passes it 
with great difficulty and in small quantity, the catheterization 
should be repeated every three hours. When, in addition to 
retention, there is infection of the posterior urethra and blad- 
der, irrigation must be practiced each time the urine is 
drained. 

In complete retention of urine, a vulcanized rubber cath- 
eter should be used. If this fails, a coudee catheter and a well 
curved one terminating in an elbow should be tried in succes- 
sion. If these are unsuccessful, a well curved cylindrical 
gum-catheter without a stylet should be employed, which 
may be given any curve at pleasure by dipping it in hot water, 
and, after bending it, into cold water. Finally it may be ne- 
cessary to employ a silver catheter with a longer curve. 

In cases of enlarged prostate of long standing it may be 
found that before the bladder is fairly entered a preprostatic 
pouch is encountered. 

When circumstances require the use of a metal catheter, the 
surgeon and not the patient should employ it. 

Whatever instrument is employed should be kept scrupu- 
lously clean. Of the three kinds employed, the metallic and 



492 DISEASES OF THE PROSTATE. 

the soft-rubber may be easily and effectually sterilized by boil- 
ing. Gum-elastic instruments are best cleansed by washing 
and syringing them through with soap and warm water. 
They should then be placed in a disinfectant solution for a 
short time, and, before used, also placed in Boric acid solution. 

Before introducing an instrument into the bladder, the fore- 
skin and glans should be well washed with soap and water 
and then swabbed with some weak antiseptic lotion. If there 
be any discharge from the urethra, the anterior part of the 
canal should be syringed out with warm Boric acid solution. 

The catheter, after use, should be washed in soap and water 
by the patient, thoroughly dried, and placed for future use in 
a corked glass tube or covered dish. The best way to dry the 
instruments is to pass them between folds of lint or gauze, in 
which they may be kept until required. (Freyer.) 

Cases are on record where men have used the catheter on 
themselves for twenty years or more. 

After the first passage of the catheter the patient should re- 
main warm and quiet preferably for an entire day. 

The patient should take especial care to keep his feet warm 
and dry for the rest of his life after once using the catheter. 

One or both testicles may swell during the use of the cath- 
eter. In most cases rest in bed on the back for a short time, 
use of bandage and tobacco-poultice or Antiphlogistine will 
relieve this condition. 

The catheters may advantageously be kept in a sterile box 
containing formaldehyde, the vapor of which prevents them 
from becoming infected. Before using the instrument the 
patient should wash his hands with soap and water and, if 
possible, with a solution of Mercuric chloride 1:1000. 

As lubricant for the instrument Freyer recommends fresh 
olive oil, or castor oil, or vaseline ; carbolic acid should not 
be used. Guyon's pomade (equal parts glycerine, powdered 
soap and water, with one per cent, naphthol) is a clean and 
efficient lubricant. Inasmuch as fatty substances cause dete- 



HYPERTROPHY OF THE PROSTATE. 493 

rioration of the rubber, trie substance known as lubrichondrin 
may advantageously be used, as it does not affect the rubber 
and is readily washed off with water. 

When in spite of intermittent catheterization, carefully con- 
ducted, the infection seems progressive, the catheterizations 
are painful, the patient is teased by a constant desire to urin- 
ate without the ability to empty the bladder, and particularly 
when the gastro-intestinal disturbances, and perhaps lumbar 
pains and fever, point to renal inflammation, a speedy death 
is inevitable unless some more radical measures be under- 
taken. 

Even under these circumstances, however, the patient can 
again be put in a condition of comparative comfort by contin- 
uous catheterization. This consists of introducing a catheter, 
preferably a soft-elbowed one, to a position just within the 
vesical sphincter, and tying it there. The end of this cath- 
eter is dipped beneath the surface of an antiseptic solution 
contained in a urinal, and the urine, as it runs into the blad- 
der from the ureters, is at once drained out. At least twice a 
day the bladder is thoroughly irrigated with an antiseptic so- 
lution, using for this purpose either Boric acid, a drachm to a 
pint; Permanganate of Potassium, 1:6000; Nargol or Protar- 
gol, i : 6000 running up to 1:1000, or Mercurol, 1:2000, in a 
normal salt solution. The urethra should also be flushed 
twice daily by withdrawing the catheter until its eye lies just 
beyond the grip of the compressor urethrae muscles. Under 
this treatment, as a rule, the fever subsides, the pain is less- 
ened and disappears in from one to two weeks. The urine 
again becomes clear, and intermittent catheterization may 
again be resumed. 

It often happens, however, that there is a prompt recur- 
rence of inflammatory symptoms. This indicates the need of 
a radical operation designed for the removal of the obstruc- 
tion. {Therapeutic Gazetted) 

The cystitis is to be treated as already described. (See 



494 DISEASES OF THE PROSTATE. 

Cystitis.) The writer, however, finds certain remedies espe- 
cially useful in the cystitis of enlarged prostate ; these are 
first, Urotropin, in dose already given ; Chimaphila and Stig- 
mata maydis. 

An excellent prescription in a palliative way is that origi- 
nally suggested to the writer by Dr. A. B. Spach, of Chicago, 
as follows : 

A mixture of the fluid extracts of Chimaphila, Taraxacum 
and Stigmata maydis, in the proportions by volume of i, 2, 3, 
in the order named. The dose is a teaspoonful every three 
hours. 

Triticum is sometimes substituted for Chimaphila in the 
above formula when the urine is scanty and there is swelling 
of the feet. 

The Taraxacum in this mixture acts efficiently in many 
cases observed both by Dr. Spach and the writer, securing a 
daily passage of the bowels. 

Further, if the urine happen to be strongly acid, Citrate of 
Potassium and French Vichy Water are exceedingly useful. 
If the above for any reason fail, lithiated corn-silk or hy- 
drangea may be used. 

Triticum repens in the preparations known as Tritica or 
combined with Saw Palmetto (tritipalm) have appeared to 
increase the urine and diminish smarting in some cases. Oil 
of Sandalwood and Saw palmetto (Sanmetto) has also great 
vogue in prostatic cases. 

If Urotropin fails to clear the urine, Boric acid should be 
given internally, dose usually ten grains four times daily, in- 
creased to twenty-five in extreme cases. Before using 
Urotropin, the writer used the formula of Ralfe, given under 
Pyelitis, in cases when the urine was ammoniacal and foul. 

Some cases are best relieved, according to Freyer, by Boric 
acid, combined with Benzoate of Ammonium, in 10-grain 
doses. Salol and Salophen are also useful as disinfectants. 
The former is used by Adams, before operations, in preference 
to Urotropin. (See Stone in the Bladder.) 



HYPERTROPHY OF THE PROSTATE. 495 

When there is much pus and foul, stinking urine, the blad- 
der must be washed out with disinfectants, or astringent 
lotions. 

Not more than two or three ounces should be thrown into 
the bladder at one time. If the cystitis be severe, not more 
than half an ounce should be used at a time. All lotions 
should be warmed to ioo° F. To cleanse the bladder the 
most simple and useful injections are a one-per-cent. solution 
of boric acid or a teaspoonful of boroglycerin to four ounces 
of water. Permanganate of potash solution commencing 
with i-in-5000 and gradually increasing it to i-in-1000, and 
perchloride of mercury i-in-10,000, make excellent injections. 
The sheet-anchor in such cases is nitrate of silver, commenc- 
ing with a weak solution, i-in-4000, gradually increasing 
this to i-in-750. 

For great pain and scalding at the neck of the bladder 
from local cystitis daily instillations of nitrate of silver are 
employed. (Freyer.) 

One of the writer's patients reports much relief from wash- 
ing the bladder every other night with dilute Permanganate 
solution which he prepares for himself as follows: 

Cover a dime with permanganate crystals, dissolve in two 
quarts of water, warmer than the temperature of the body, 
and inject one quart in all into the bladder. 

Another of the writer's patients who complained of burn- 
ing and smarting in the urethra was made very comfortable 
by use of Urotropin internally and injections of oxy chlorine 
solution. There was, however, not much cystitis in this lat- 
ter case. 

Haemorrhage rarely occurs early, but is likely to take place 
in the later stages; the blood may come from either the blad- 
der or prostate. The treatment consists in perfect rest in bed 
and the administration of sedatives or narcotics. Frequent 
haemorrhage, attended by much pain after exercise in prostatic 
patients, should always give rise to the suspicion of the pres- 
ence of stone. 



496 DISEASES OF THE PROSTATE. 

In severe haemorrhages rectal injections of hot water, with 
or without brandy, are of great value if there is circulation 
enough to cause absorption by the bowel. In cases where the 
heart action is very feeble, venous transfusion of normal salt 
solution must be made. If for any reason this cannot be 
done, hypodermics of ether, in doses of ten minims every ten 
or fifteen minutes, until five or six doses have been given, 
may cause the patient to rally. 

If the normal salt is used the solution employed should con- 
tain one drachm of salt to 1 the pint, and must have a tem- 
perature of from ioi° to 102 F. It will cool down to blood 
heat while passing through the transfusion apparatus. Care 
should be taken to see that the temperature is maintained 
during the operation, and this can most easily be done if the 
solution be prepared in small quantities at a time. It should 
in all cases be filtered through muslin before use. If it be 
necessary to repeat the transfusion, another vein must be 
opened. When the patient has been revived and the im- 
mediate danger of death from syncope is staved off, the ex- 
treme restlessness and headache that so frequently follow 
may be treated by large doses of opium or morphine. Any 
further tendency to syncope is best treated by raising the 
foot of the bed, and the administration of liquid food and 
stimulants in small quantities at frequent intervals. The 
great risk of subsequent sepsis must not be forgotten, and the 
convalescence of such patients is of necessity a slow process. 
(Freyer.) 

Treatment by Electro- Cataphoresis. — Iodine is applied 
cataphorically from a solution of Iodide of Potassium, either 
through the rectum or through the urethra. The treatment 
through the rectum is not so severe as through the urethra. 
It requires skill and manipulative ability. The writer has 
seen a case which was considerably aggravated by this pro- 
cedure. The methods are as follows: 

After placing the patient in the proper position, the rectum 



HYPERTROPHY OF THE PROSTATE. 497 

carefully cleansed, a speculum inserted and the prostate ex- 
posed, the medicament is carried to the prostate by means of 
a suitable electrode, covered with moist gauze, carbolated 5 
per cent, and then soaked in the medicament. The time re- 
quired for cataphoresis depends upon the condition of the 
prostate. 

The treatment through the urethra is easily accomplished 
by using an applicator composed of a hard rubber tube closed 
at the distal end with a hard rubber plug ; for about two 
inches from the distal end a number of small holes are drilled 
in the tube. A copper wire, to which the electrode is at- 
tached, is wound with absorbent cotton and dipped in the 
solution, then inserted in the applicator, which has previously 
been carried into the prostatic urethra. A current of 10 mill- 
iamperes is all that is necessary. 

The solution of Potassum iodide must be applied from the 
negative pole, in order to get the resolvent effects of the 
iodine in the enlarged gland. 

Operative Treatment. — Among the various operations pro- 
posed for enlarged prostate are prostatectomy, the Bottini op- 
eration, vasectomy and castration. According to Adams, the 
best general operation is perineal prostatectomy, and the time 
for operating is as soon as obstructive retention takes place. 
As a rule, the longer the patient uses the catheter the less fit 
he is for operation. 

According to Reginald Harrison, in cases where the upper 
portion of the enlarged prostate interferes with urination by 
projecting into the trigone, the Bottini operation is most effi- 
cient. 

The latter operation, if performed, should be done by an 
expert only, as it requires skill and practice. According to 
Bransford Lewis, many a feeble old man may be operated on 
by this means who would almost certainly be killed by other 
curative means, notably by prostatectomy. Many another, 
who- suffers from urinary obstruction simply because of a 
32 



498 DISEASES OF THE PROSTATE. 

prostatic "collar" surrounding his internal urethral orifice, 
can be cured by this simple and innocuous procedure, free 
from large haemorrhage, open wound, an avenue for septic ab- 
sorption and infection, continued surgical drainage through 
an artificial channel, the loss of tissues, etc., done with local, 
instead of general, anaesthesia, as well as he can be cured by 
the more heroic and radical measures. 

The Bottini operation consists in making incisions in the 
prostate by means of a blade heated red-hot by electricity. It 
can be done by use of Cocaine instead of general anaesthesia. 
As a rule, active haemorrhage is absent, and usually the only 
complaint after the operation is a temporary increase in the 
burning on urination. In some cases, owing to the swelling 
incident to the operation, there may be complete retention ; in 
such a case catheterizing is necessary for a time. According 
to Lewis, the after-treatment, aside from the invariable exhi- 
bition of the internal antiseptics, varies with the course of the 
case. If all goes well, there is practically no after-treatment 
except rest in bed for two or three days, light diet, and the 
securing of personal cleanliness. But in certain cases trouble- 
some features arise, such as painful contractures at the vesical 
neck, coming on periodically, with the accumulation of urine 
in the bladder. This necessitates the giving of rectal suppos- 
itories at sufficient intervals to prevent them, or of hot water 
enemata, which have an exceedingly beneficial effect also. 
There is occasionally dribbling of urine for a few days, but 
this is rather gratifying than otherwise, indicating the re_ 
moval of the obstruction and the retention that have so long 
dominated the scene. A porcelain urinal kept under the penis 
prevents wetting of the bed. The dribbling seldom lasts 
longer than a few days after a Bottini operation. 

In a number of cases it has been noticed that the second or 
third day brings a sudden rise of temperature to 101 degrees 
or more ; but it has also been noticed that this soon subsides 
and does not recur, whether special measures are undertaken 
to accomplish that end or not. 



HYPERTROPHY OF THE PROSTATE. 499 

One after-effect that is disagreeable but which does occur 
sometimes, is continued haemorrhage from the prostatic 
urethra. It is nearly always easily controlled, however, by 
leaving a soft-rubber catheter a demeure for twenty-four or 
more hours. It is thought to be especially likely to occur 
with the spongy prostates, indicating the glandular rather 
than the fibrous form of hypertrophy. 

The patient should drink freely of some good, pure water 
at this period to keep his urinary apparatus washed out as 
well as possible. To accelerate the urine flow Lewis suggests 
one or two tablespoonfuls of sugar of milk (saccharum lactis) 
in a glass of good water every two or three hours. It is a 
perfectly bland and unirritating diuretic. 

Freeman {Denver Med. Times) sums up the advantages of 
the operation as follows: 

i. "There is no mutilation and no external wound, the 
manipulations being carried out through the urethra. 

2. A general anaesthetic, so dangerous in the old and debili- 
tated, is not often necessary, local anaesthesia being usually 
sufficient. 

3. There is very little haemorrhage, the vessels being sealed 
by cauterization. 

4. There is comparatively small danger of serious infection, 
and usually but moderate rise in temperature, the wound be- 
ing necessarily aseptic. The charred surfaces tend to prevent 
absorption until granulations appear. 

5. In most instances patients may sit up and even walk 
about in a few days, which is of great advantage in those who 
are old and feeble. 

6. The effects may be almost immediate, more or less urine 
being voided within a few hours, where it was previously im- 
possible to pass a drop. 

7. But few relapses have been observed ; in fact, improve- 
ment has a tendency to be progressive. 

8. The operation may be repeated, if for any reason the at- 
tempt has been unsatisfactory. 



500 DISEASES OF THE PROSTATE. 

9. The mortality is lower than with other effective measures. 

10. Patients will avail themselves of this method of treat- 
ment when they will refuse to submit to castration, pros- 
tatectomy, etc." 

On the other hand, as suggested by Adams, there are certain 
objections to the operation as follows: 

1. The operator is working in the dark. 

2. The blade may bend during the operation. 

3. There is difficulty in regulating the depth of the in- 
cision. 



'% 




Fig. 32. — A healthj' prostate from a man aged thirty-five years, with its posterior or 
rectal surface downward — the internal meatus being "seen above, and the ejaculatory 
ducts in their depression below. — (Thompson.) 

4. Accidents happen, such as burning into the rectum. 

The operation should, therefore, be undertaken only by an 
expert, in whose hands it is undoubtedly serviceable in many 
cases. . 

Perineal prostatectojny may be performed by making the 
prerectal flap incision of Otto Zuckerkandl; this is a curved 
incision from one tuberosity of the ischium to the other in 
front of the anus by which the fascia are cut. The muscles 
are then separated and the rectum is separated from the 
urethra by dry dissection, and this reveals the capsule of the 
prostate from which the gland is enucleated. 

Hyperaemia. — This occurs normally during venereal excite- 



ACUTE PROSTATITIS. 501 

ment, and results, when the appetite is not gratified, in the 
secretion of a peculiar viscid mucus, which appears mixed 
with urethral mucus at the meatus. It is common in the case 
of continent men during the period before marriage, and re- 
quires no treatment save rest from sexual excitement, or a 
cold sitz-bath occasionally. The patient should be assured 
that the discharge is not seminal, which may be ascertained 
by microscopic examination. 

In old urinary cases severe prostatic congestion sometimes 
takes place, resulting in complete retention of urine, and, un- 
less the latter be drawn off, severe symptoms, suggesting py- 
elonephritis, may ensue. 

Treatment.— Thuja, Conium and Secale are the principal 
remedies. In some cases, dependent on arterio-sclerosis, 
Iodide of Potash, thirty grains in four ounces of water, a tea- 
spoonful slightly diluted twice daily. 

Alcohol, spiced foods, and long sitting, as in a buggy or 
railway car, or on a bicycle, are to be avoided. 

Sexual excess, constipation and diseases of the rectum ag- 
gravate the condition. 

ACUTE PROSTATITIS. 

Definition. — Acute inflammation of the prostate. 

Varieties. — Acute prostatitis may be either catarrhal, fol- 
licular or suppurative also called parenchymatous. 

Follicular prostatitis is characterized by an obstruction of 
the follicles with the formation of small sacs containing des- 
quamated epithelium, leucocytes and debris. It is, however, 
clinically chiefly chronic. 

Suppurative prostatitis is the usual acute form. It is char- 
acterized either by the formation of small abscesses or by a 
diffuse phlegmonous inflammation, with, at times, complete 
destruction of the gland-tissue. 

The prostate is at first congested, then inflamed ; finally res- 



502 DISEASES OF THE PROSTATE. 

olution takes place, pus exudes on the free surface or there is 
croupous exudation ; abscess or peri-prostatic formation of 
pus may take place, or the disease linger indefinitely as a 
chronic follicular inflammation. 

In cases of suppurative peri-prostatitis, thrombosis of the 
veins of the prostatic plexus is likely to take place, and soften- 
ing of the thrombi not rarely gives rise to septic embolism and 
general pyaemia. The abscesses may burst into the urethra, 
or the suppuration may end in fibrosis of the prostate, with 
gradual atrophy. 

Etiology. — Rarely a primary disorder. We find it second- 
ary to the following conditions : 

Gonorrhoea. 

Stricture. 

Irritation from various causes : acid urine of high specific 
gravity, use of instruments, fragments of stone, strong injec- 
tions, drugs, like Cantharides, internally. 

It is claimed that riding the bicycle causes acute prostatitis, 
but, in the writer's experience, those patients who have re- 
ferred their trouble to this cause have obviously done so in 
order to conceal the history of a previous gonorrhoea. 

Sexual excess, constipation and rectal disease are predispos- 
ing causes. 

Prostatitis occurs also in infectious diseases, small-pox, pyae- 
mia, glanders and typhoid fever. 

The bacteria concerned in it are chiefly the pyogenic cocci, 
the gonococcus and the Bacillus coli communis. 

Clinical Features. — These may be summarized as follows : 

Rapid swelling of the prostate, which, to the finger in the 
rectum, may feel as large as a small orange. 

Exceeding sensitiveness of the organ to the touch, which 
excites immediate desire to urinate. 

Feeling on part of the patient of something protruding into 
the rectum, causing in some cases ineffectual attempts at stool. 

Heat, weight and throbbing sensations locally. 



ACUTE PROSTATITIS. 503 

Various other symptoms or sensations, as dragging pain in 
back or limbs. 

Diminution of urethral discharge to a greater or less degree 
for the time being. 

Constant desire to urinate without sense of relief, and with 
pain as the last drops pass, when the circular fibres at the 
neck of the bladder squeeze the tender prostate. 

Febrile disturbance. 

Great mental disturbance, out of proportion to the magni- 
tude of the disorder. Mild acute mania, even, occurs in some 
cases. 

Not infrequently the abscess opens in two directions, giving 
rise to fistulse, which, if unrevealed, render the life of the 
patient wretched beyond description. 

Prognosis. — The degree of fever is a valuable criterion on 
which to base an opinion. If the temperature does not rise 
above ioi° F., and is unaccompanied by chills, sweating and 
prostration, resolution without suppuration will probably oc- 
cur. 

Resolution, when occurring, takes place between fourth and 
twelfth day ; recovery in from one to three weeks. 

Unfavorable signs are marked chills, high fever, and con- 
siderable diminution of perineal pain and tension, indicating 
suppuration instead of resolution. If the abscesses are small 
the prognosis is still good, but where the collection of pus is 
very extensive the prognosis must be guarded. 

Treatment. — The essentials are the following: 

i. Absolute repose in bed with a non-nitrogenous diet. 

2. Alkaline waters, as Vichy. 

3. Morphine in quantity just sufficient to control severe 
pain and excessive action of the bladder. 

4. Copious enemata of hot water for the bowels. No 
cathartics, unless necessary; then give Castor oil. 

5. Suppositories, as of codeine, gently introduced, to modify 
the incessant desire to urinate. 



504 DISEASES OF THE PROSTATE. 

6. In severe cases leeches to the perinaeum, followed by hot 
sitz-baths and hot rectal enemata, repeated three or four times 
daily. 

Or the measure advocated by some German surgeons of ap- 
plication of cold direct to the prostate by use of a rectal sound 
and stream of iced water. 

A case is reported in which the pain and sense of weight 
were relieved by a galvanic current of from five to seven mill- 
iamperes, the positive pole being placed in the urethra and 
the negative over the perinaeum. 

The remedies usually indicated are Bryonia, Mercurius, and 
Pulsatilla. Bryonia and Pulsatilla in drop doses of the tinct- 
ure every two hours. Mercurius solubilis in the first tritu- 
ration, four grains in seven ounces of water, a teaspoonful 
every two hours. 

Gelsemium and pichi in the lower decimals may also be 
needed. 



PROSTATIC AND PERI-PR OSTATIC ABSCESS. 

During the course of acute prostatitis pus formation is 
shown by the symptoms already described under Prognosis. 
The pain is less tense and of a more lancinating character. 
Retention of urine may result from pressure in the already 
narrowed urethra. 

Less marked and less intense symptoms are found in peri- 
prostatic cases. (CEdema felt by the finger in the rectum 
serves to distinguish peri-prostatic abscess.) 

Treatment. — If the abscess bursts spontaneously, all pain 
and discomfort cease like magic. But, owing to the dense 
nature of the fibrous capsule of the prostate, it is often tardy 
in opening. 

When fluctuation can be made out through the rectum, 
puncture with a trocar is to be made. 

When the bulging into the urethra produces retention 



CHRONIC PROSTATITIS. 505 

without yielding fluctuation, pneumatic aspiration of the ab- 
scess through the rectum is advised. Or aspiration several 
times daily above the pubes to draw off the urine ; or careful 
attempts to relieve the bladder with a silver catheter. 



CHRONIC PROSTATITIS. 

Chronic prostatitis may be, (a) strictly follicular, (J?) follic- 
ular and parenchymatous combined, or (c) tubercular. 

Etiology. — Chronic follicular prostatitis usually follows 
acute gonorrhoeal prostatitis. It may also come on insidiously 
after gonorrhoea without previous acute disease of the 
prostate. 

Pathologic Anatomy. — The disease involves the mucous sur- 
face of the sinus of the prostate and of the mucous follicles 
and ducts. There is a discharge of a more or less viscid se- 
cretion, containing desquamated epithelium, leukocytes, amy- 
laceous bodies, Bottcher's crystals, and peculiar casts some- 
what resembling tube-casts of the hyaline variety. The 
prostate may be smaller or larger than normal and is either 
soft and dirty-brown in color, or fibroid and glistening. 
Microscopically, we find the lumen of the tubules filled with 
the epithelia, leukocytes and amylaceous bodies mentioned 
above and about the glands are leukocytes and newly formed 
spindle cells. 

Cicatricial bands by contraction may either occlude the 
ejaculatory ducts or tend to keep them patulous and thus 
cause spermatorrhoea. 

Clinical Features. — These are the following: 

Slight muco-purulent oozing from the meatus, increased 
by straining at stool (prostatorrhea). 

In some cases painful defecation. 

In the combined cases of chronic follicular and parenchy- 
matous disease we have the following: 

Weight and dragging-down sensation toward the perinseum, 
with painful feeling in the prostate. 



506 DISEASES OF THE PROSTATE. 

Painful sensation when walking. 

Increase of pain on crossing the legs; finally also from sit- 
ting, or in changing from sitting to standing, and vice versa. 

The symptoms and urine of stone in the bladder. 

Great mental depression. 

The finger in the rectum finds slight enlargement and heat 
of the prostate, with perhaps increased sensibility, and sound- 
ing finds the prostatic urethra exceedingly sensitive without 
presence of stone in the bladder. 

Treatment. — Keyes advises repeated mild blistering of the 
perinaeum for weeks, if necessary, by painting cantharidal col- 
lodion upon one side of the perinseum, confining the patient 
to bed for forty-eight hours, and painting the other side of the 
raphe as soon as the soreness of the first begins to subside. 
Great care is necessary to avoid the scrotum and anus in this 
procedure. Binding up the scrotum and covering the blis- 
tered surface is necessary. 

Nutritious diet, alkaline waters, and free movements of the 
bowels are necessary. 

Phosphoric acid and Phosphate of Strychnine are the chief 
remedies internally. 

Massage of the prostate is now much used in the treatment 
of chronic gonorrhceal prostatitis. Lydston, of Chicage, rec- 
ommends the follywing procedure : 

The latero-prone position, with the buttocks upon the edge 
of the table so as to be easily accessible to the operator, and the 
knees well drawn up toward the chest, is most satisfactory. It 
is as difficult to instruct the inexperienced in the technique of 
prostatic massage as it is to describe the sound of a violin. 
Much depends upon the tactile sensibility and education of 
the finger. In a general way, prostatic massage requires that 
not only the prostate proper, but the peri-prostatic tissue 
should be stroked and rubbed with the pulp of the finger to- 
wards the median line, and forward toward the operator. The 
seminal vesicles, prostate and peri-prostatic tissue at the neck 



TUBERCULAR PROSTATITIS. 507 

of the bladder represent an equilateral triangle, the apex of 
which corresponds to the apex of the prostate, and the base to 
a line drawn between the upper extremities of the seminal 
vesicles. The massage should be applied obliquely toward 
the median line and apex of the prostate. As a rule, all of 
the tissues within this triangular area should be thoroughly 
massaged. The amount of pressure depends upon the toler- 
ance of the patient, the sensibility of the prostate, and the 
chronicity of the inflammation. It should be gentle at first, 
and gradually increased pari passu with the increase in the 
tolerance of the patient. 

The frequency with which massage should be administered 
necessarily depends upon circumstances. Some patients toler- 
ate the operation daily with manifest advantage. Compara- 
tively few, however, tolerate it oftener than every other day, 
and in by far the majority of cases twice weekly is best. The 
massage may be combined with through and through irriga- 
tions of various antiseptic solutions, of which the Permangan- 
ate of Potassium, Nitrate of Silver, Albargin and Sulphate of 
Copper are the most useful. 

TUBERCULAR PROSTATITIS. 

Etiology. — It is most frequent in young adults who are 
tuberculous or debilitated. It is generally a part of urogeni- 
tal tuberculosis, but may be primary from hematogenic infec- 
tion. 

Pathologic Anatomy. — The prostate is enlarged and usu- 
ally cheesy degeneration is the feature ; more rarely then are 
typical miliary tubercles. The caseous sacs may rupture into 
the rectum, urethra or bladder, and, in rare instances, a gen- 
eral miliary tuberculosis is produced. 

Clinical Features. — These are the symptoms of severe 
chronic prostatitis: 

The contour of the prostate felt per rectum is lumpy. 



508 DISEASES OF THE PROSTATE. 

The course of one or both vasa deferentia can be traced as 
an infiltrated hard tube, joined to a distinctly enlarged, knot- 
ted, indurated seminal vesicle. 

Steady aggravation of symptoms is noticed. 

Slight haemorrhages take place from the urethra from time 
to time without relief. 

There are tubercle bacilli in the urine. 

Course and Prognosis. — The course is exceedingly slow 
and the prognosis bad. 

Treatment. — Occasionly cures are effected by the usual 
anti-tubercular measures of hygiene, diet, climate, and 
medication. 

CARCINOMA OF THE PROSTATE. 

This is exceedingly rare and often overlooked. The growth 
is of the nature of adenocarcinoma. 

Etiology. — It may occur in youth, but is usually observed 
in advanced age. It may be engrafted upon antecedent 
hypertrophy. In a case observed by the writer, that of a man 
seventy-five years of age, the condition was that of ordinary 
hypertrophy for five years, prior to the development of 
carcinoma. 

Pathologic Anatomy. — The appearance is that of simple 
hypertrophy, which may be as large as a hen's egg, nodular 
and very hard; or there may be large, well-defined tumors. 
Occasionally the surface of section is suggestive of tuber- 
culosis. - There is marked tendency to metastasis, and the ex- 
tent of the secondary growths is out of proportion to the size 
of the primary tumor. Metastasis occurs early to the inguinal 
lymph-glands; also to the retroperitoneal and' pelvic glands, 
and to those along the aorta and vertebrae. There is frequent 
metastasis to the bony skeleton, the secondary growths being 
characterized by formation of osseous tissue, hence the term 
osteoplastic carcinoma. There may be also metastasis to the 



TUBERCULAR PROSTATITIS. 509 

liver and the rectal wall may be infiltrated and adherent to 
the tumor. 

Post-Mortem Appearances. — In Madison's case these were 
as follows: 

Post-mortem showed a scirrhus of the prostate gland about 
as large as a hen's egg^ nodular and very hard. The peri- 
tonaeum was also infiltrated with cancerous masses. There 
was also a small secondary cancer of the liver, some portions 
of which had undergone calcareous degeneration. The blad- 
der contained about one ounce of purulent liquid, evidently 
partly urine, partly pus. The mucous membrane at the base 
of the organ, while extremely red, could hardly be said to be 
ulcerated. A more correct description of it would be con- 
veyed by the term granular inflammation. The rectal wall 
was infiltrated by the growth and was adherent to the tumor, 
although rectal symptoms were surprisingly few and slight, 
being practically limited to pain on defecation. 

Clinical Features. — These are the following : Free haemor- 
rhages from the urethra, either spontaneous or during urina- 
tion, with relief to the symptoms and pain ; the discovery of 
shreds of tissue of considerable size in the urine ; if scirrhous 
cancer, the peculiar hardness of the prostate felt per rectum ; 
if medullary, certain spots softer than others in the prostate ; 
enlargement of the glands in the groin and pelvis. 

The most prominent symptoms are frequent desire to urin- 
ate, pain upon defecation, and intense pain in the region of 
the bladder and prostate gland, emaciation, and loss of appe- 
tite. 

Cancherous cachexia is slow in appearing ; in the case ob- 
served by the writer it was postponed until a month or two 
before death. 

The Urine. — This may show the features of previous hyper- 
trophied prostate or may, according to Madison, be normal so 
far as chemical analysis goes. 

Madison observed a growth no larger than a hen's egg, 



510 DISEASES OF THE PROSTATE. 

which had not ulcerated, and which caused no pressure-symp- 
tom whatever excepting inability to urinate. The urine, to 
within a few days of death, remained entirely normal as far as 
chemical analysis showed. The microscope only showed a 
small amount of mucus from the bladder. There was never 
any rectal discharge, and the post-mortem showed no break- 
ing down of the tumor. And still the growth caused death. 

Prognosis and Treatment. — The prognosis is bad and the 
treatment practically nil. In Madison's case the patient had 
to have, during the last three weeks of his illness, four grains 
of Morphine, hypodermically, every four hours, and this 
amount did not produce complete narcosis, the effect lasting 
only from two to three hours. A hypodermic needle was 
used on this case something over one thousand times. 

OTHER TUMORS. 

Sarcoma is rare. It may be of the round-cell or spindle-cell 
type. It may spread locally, but, as a rule, does not involve 
the lymph-glands. Metastasis is usually to the lungs or liver, 
rarely to the bones. 

Cysts are due to obstruction of the gland-ducts or to dilata- 
tion of rests of the Miillerian ducts. In rare cases cysts of 
echinococcus occur. 

CONCRETIONS OF THE PROSTATE. 

The corpora amylacea may coalesce and by incrustation 
with lime salts be transformed into calculi chiefly phosphatic. 
They are exceedingly hard, with a polished surface. If large, 
they may lead to prostatic obstruction and cause chronic cys- 
titis or atrophy. If they project into the urethra, a metallic 
instrument may be felt to grate on them. If they cause dis- 
tressing symptoms, Keyes advises perineal opening and ex- 
traction. 



CHAPTER XVIII. 

DISEASES OF THE URETHRA. 

Malformations of the urethra are as follows: Absence, con- 
genital stricture, epispadia, hypospadia, doubling, and congen- 
ital fistulas. 

Wounds and Ruptures. — False passages may be produced 
by the passage of instruments. Surgical wounds heal readily 
without stricture, when longitudinal, but transverse wounds 
lead to formation eventually of stricture. Accidental injuries 
may be due to passage of foreign bodies and to external vio- 
lence. Subcutaneous rupture is most common in the perineal 
portion and results in extravasation of urine; rupture may 
take place in the case of women during labor. 

According to J. R. Hayden, when there is marked haemor- 
rhage with retention, or bloody urine associated with inability 
to enter the bladder with instruments; also, if there is a fluc- 
tuating perineal tumor with, perhaps, a rise in temperature, 
perineal section and bladder drainage are indicated. In other 
cases, catheterization, irrigation, and urinary antiseptics 
should be resorted to, and watch kept for the first sign of 
urinary extravasation, in which event external urethrotomy 
with vesical drainage should be resorted to. Partial suture 
of the urethra should be employed when the divided ends are 
widely separated. Complete suture is, in general, contrain- 
dicated. 

Haemorrhage. — This occasionally takes place after coitus ; 
it is more commonly due to injuries and inflammations. If 
from the anterior urethra, blood may be squeezed out of the 
meatus by pressure with the fingers. 

It may take place in severe cases of gonorrhoea, in impacted 
calculus of the urethra, and after use of the catheter. 



512 DISEASES OF THE URETHRA. 

Stricture. — This is due either to gonorrhoea or wounds and 
injuries. In the latter case the stricture appears soon after 
the injury, but in the former usually not before a year after 
the acute attack. Stricture may result in dilatation of the 
urethra and of the neck of the bladder behind the stricture, 
in prostatitis, hypertrophy of the bladder, and often cystitis, 
ureteritis and pyelonephritis. Periurethral abscesses and uri- 
nary infiltration are not uncommon results. 

Tuberculosis. — In descending urogenital tuberculosis, the 
urethra may be involved, usually the prostatic portion, but 
sometimes the whole urethra ; or urethral tuberculosis may 
be an extension from tuberculosis of the penis. In women 
lupus of the vulva may implicate the urethra. 

Syphilis. — Chancre, chancroid, and gumma are possible 
in the urethra. Leprous lesions sometimes occur. 

Tumors. — Cystic and papillomatous hyperplasias occur 
more commonly in women, but in general are rare. 

Carcinoma is rare but may occur in old age in the form of 
squamous epithelioma. Adenocarcinoma may develop from 
Cowper's glands. 

The growth may be secondary by extension from the glans 
or the prostate. Sarcoma is exceedingly rare and usually 
secondary, by extension from the penis. 

Calculi and Foreign Bodies. — Calculi may be found lodged 
in the urethra behind strictures and coming usually from 
higher up in the urinary tract. 

These may reach a large size. A lump is found in the per- 
inaeum which use of the sound shows to be stone in the 
urethra. P. M. Ashburn, of Batavia, Ohio, found one of un- 
usual size, shown in the figure. 

It was 2 }4, in. long and i % in. in diameter. It was white 
on the inside, very hard, shaped and looked much like a po- 
tato. It weighed dry 660 grains. At one end of it was a 
polished surface that corresponded with a similar surface on 
the smaller stone, which lay against it. This second stone 



POSTERIOR URETHRITIS. 513 

was of the same appearance, shaped much like a Lima bean, 
and weighed dry 60 grains. 

Jopson, in American Journal of Medical Sciences, reports 
two cases of impacted calculus in the urethra of children. The 
first, a boy of three, had difficulty in urination for about two 
weeks. For 28 hours before admission he passed no urine, 
and had been very restless. The abdomen and scrotum and 
thighs were swollen and tender. A diagnosis of urinary ex- 
travasation was made, probably due to rupture from impacted 
calculus. At operation a small red, rough stone was found in 
the spongy urethra. The child did well for three days, and 
then developed an attack of what was apparently scarlet 




Fig. 33. 

fever. It improved and then grew worse and died in collapse. 
The second patient, a boy, three and one-half years of age, 
had complained of pain over the bladder and passed no urine 
for 24 hours. When a catheter was passed, a stone could be 
felt in the urethra. Median urethrotomy was performed 
and a smooth round stone removed. The patient recovered 
satisfactorily. Jopson believes that the retention is usually 
reflex in character. The operation is often difficult. 

A great variety of foreign bodies may be introduced from 
without. (See works on Surgery.) 

In cases of necrosis of the pelvis, spicules of bone have 
been known to lodge in the urethral canal. 

33 



514 DISEASES OF THE URETHRA. 



INFLAMMATIONS. 

A common complication of gonorrhoea is posterior ure- 
thritis, occurring in from sixteen to eighty per cent, of the 
cases, according to different authorities. 

POSTERIOR URETHRITIS. 

Definition. — An inflammation of that portion of the ure- 
thral mucous membrane between the bulbo-membranous por- 
tion and the bladder. 

Occurrence. — In males any time after the third week of an 
attack of gonorrhoea. 

Clinical Features. — These are the following in the more 
severe cases : 

i. Great frequency of urination, great urgency, and painful 
tenesmus. 

2. Radiating pains and free haemorrhage at the close of 
micturition. 

3. Heightened reflex sexual irritability and abnormalities 
of the sexual function. 

Diagnosis. — This is made by the two-glass test of the urine. 
The patient passes his urine into two glasses : the first por- 
tion represents the urine of the bladder plus the washings of 
the urethra ; the second that of the bladder only. If no dis- 
ease of the bladder or kidneys is present, pus in the second 
glas*s always means posterior urethritis. The examination 
should be made after long retention, and also again after a 
short retention. After short retention, if the second glass is 
clear, cystitis is excluded. 

Pyelitis must be excluded by absence of the features of 
that disease, which have been already mentioned. The age 
of the patient and the history of recent gonorrhoea usually 
serves to distinguish the two. Considerable albumin is often 



POSTERIOR URETHRITIS. 



515 




found in severe cases of this dis- 
order, which may lead the phy- 
sician to suspect renal trouble 
which does not exist, other than 
what is probably a renal conges- 
tion. 

Prognosis. — Complete recovery 
from gonorrhoea complicated by 
posterior urethritis is uncertain. 
There is possibility of extension 
to the bladder, seminal vesicles, 
and testicles. 

Treatment. — In acute cases 
avoidance of stimulating and salty 
foods, alcoholic beverages, etc., as 
in acute cystitis. The remedies 
already mentioned under Cystitis 
are of service. Chronic cases re- 
quire surgical treatment (irriga- 
tion), and often resist treatment 
entirely. In obstinate cases cau- 
terization is sometimes employed. 

The writer has seen cases 
which were aggravated by surgi- 
g cal treatment improve consider- 
ably when irrigations were stop- 
ped. 

Frequency of urination with 
pain is sometimes due to disease 
of the deep urethra, mistaken for 
cystitis or irritable bladder. 

The morbid condition is usual- 
ly confined to the mucous mem- 
brane and submucous tissues. In 
almost all cases there is a 



Fig. 34. 



*avicuiaris™L?™ color of the mucous 

bulb ; d, the membranous portion 
prostatic portion.— (From Finger.) 



membrane, varying between a 



516 DISEASES OF THE URETHRA. 

rose pink and slight purple, some cases presenting a 
granular surface. The diseased part will often bleed on 
touch. There may be, and usually is, some uneasiness about 
the base of the bladder, and when the desire to urinate is de- 
cidedly present, the discomfort is marked, nagging, and ex- 
ceedingly uncomfortable. (Hawes.) 

The endoscope is of service in making the diagnosis. The 
diagnosis having been settled, an ordinary urethral speculum 
of a caliber as large as can be borne with comfort should be 
passed through the deep urethra. With absorbent cotton on 
a cotton-carrier the mucus at the bottom of the speculum 
should be taken up, and if any blood has filled the lumen it 
should be mopped away until the mucous membrane is dry. 
Another carrier, having a small ovoid of cotton on its point, 
nearly saturated with guaiacol, may be used to make applica- 
tions to the congested membrane. 

Guaiacol in a fluid condition should not be permitted to 
cover the mucous membrane ; barely enough to make a sur- 
face application is all that is desirable ; thus applied it is an 
anaesthetic and mild stimulant. It gives rise to much less 
pain than the usual local applications. No strangury results, 
as is usually the case when silver nitrate is used. The patient 
will often retain the urine for hours after the application. Its 
use is often followed by a lessening of the perineal and supra- 
pubic discomfort after a few hours, and a few applications, 
from five to ten days apart, have been more satisfactory to 
patient and physician than any remedy previously used. It 
has cured twenty per cent, of Hawes' patients. About seventy 
per cent, of the cases are improved markedly. Some cases 
that would seem to fall fairly within our field are not im- 
proved. If applied every day or two it will produce local 
tumefaction, causing a diminished size of the urinary stream; 
this tumefaction passes away in a few days. (Hawes.) 



URETHRITIS. 517 



URETHRITIS. 

If the suppuration is in the urethra anterior to the com- 
pressor urethrse, there is never tenesmus or any uncontrol- 
lable desire to urinate, but merely a severe smarting sensa- 
tion as the urine passes along the urethra. In acute urethritis 
the mouth of the urethra is usually swollen and reddened. 

Treatment. — Catarrhal urethritis is usually of but short 
duration, and often disappears in a few days, if the causes of 
it, as catheterizing, masturbation, etc., are removed. 

Gonorrhceal Urethritis begins about three days after ex- 
posure, and in uncomplicated cases the patient begins to im- 
prove by the twentieth day, whereas non-specific urethritis 
seldom lasts over twelve. 

Microscopic examination for the gonococcus is necessary 
for differential diagnosis. 

The treatment of gonorrhoea cannot be considered in full 
here, owing to the magnitude of the subject. The essentials 
are as follows: 

1. Diet and hygiene. 

2. Administration of alkalies. 

3. Use of indicated remedies. 

4. Local treatment by injections. 

Unirritating diet free from alcohol, spices and acids, absti- 
nence from tobacco and sexual excitement, rest, if possible 
in bed, are all useful. The urine should be kept alkaline 
with Potassium Citrate or Acetate or a mixture of both. 
Aconite, first decimal, and Gelsemium tincture should be given 
early in the disease, followed on the second or fourth day by 
Cannabis sativa and Argentum nitricum. Later Copaiva 
and Sandalwood, in the second or third week and in appreci- 
able doses. 

According to Carleton, "during the first week of the dis- 
ease prescribe a urethral injection after each urination, to be 



518 DISEASES OF THE URETHRA. 

retained three minutes, of i to 2 drachms of a y^ of 1 per cent, 
solution of Protargol. The second week alternate the pro- 
targol solution with a warm 1-4000 solution of permanganate 
of potash ; in the third week discontinue the protargol and 
alternate the permanganate with a 1-1000 solution of zinc 
sulphate, each ounce of the zinc solution to contain one 
drachm of Lloyd's hydrastis. If the discharge continues after 
this period, use the zinc solution in increasing strength up to 
3 grains to the ounce, three times daily until cured. Local 
lesions and complications will require their special treatment. 
If congenital effects are present, or are acquired, they must 
be surgically removed before a perfect cure can be expected. 

If the posterior urethra becomes involved, local medication 
must be discontinued, with the possible exception of instilla- 
tions every second day of a few drops of a 1-1000 to 1-500 
solution of nitrate of silver. These applications are best 
made with the Taylor syringe and a No. 1 1 F. catheter, cut 
eight inches in length, the eye of which, when fully intro- 
duced, will be in the prostatic urethra. The catheter should 
be lubricated with lubrichondrin, and while it is being slowly 
introduced, a few ounces of a hot boric acid solution should 
be discharged through it into the canal to ' wash the latter 
free from infected matter and prevent carrying it to the 
deeper parts. Hot sitz baths and rectal irrigations, using z 
quarts of a 3-10 of 1 per cent. Saline solution or filtered cam- 
omile tea, often give much relief. The remedies found most 
efficacious in addition to those mentioned are Piper menth., 
Picric acid, Petroselinum, Buchu, Gelsemium, Mercurius, 
Cantharis, etc. (See note on Argyrol, last chapter of book.) 

In some cases in which I have been unable to relieve by 
the indicated remedy I have used with immediate results a 
shot-gun prescription recommended by the late Dr. E. M. 
Hale, which is as follows: 

I*. Ralsami Copaivas, Olei Santali, aa ^ ss. 

Olei Cinnamomi % i. 

Emulsi Acaciae % iiiss. 

Elixirii Simplicis^^ 5 vi. 



URINARY FEVER. 519 

Sig.: Two teaspoonfuls every four hours. 

The immediate relief which it has given is sometimes as- 
tonishing as well as particularly satisfactory." 

In chronic cases, so-called gleet, the writer has seen some 
remarkable results follow the administration of an Eng- 
lish mixture known as Liquor Santali cum Buchu et Copaiba. 
Its effect on the digestion may be unpleasant, but its curative 
action outweighs this effect. 

Urethritis in women is often a very troublesome disorder 
and may be mistaken for cystitis. Gramm in chronic cases 
recommends application of stronger solutions of Silver salts 
or urethral injection of Antinosine, 2 per cent, twice daily. 

URINARY FEVER. 

Synonyms. — Catheter fever, urethral fever. It has also 
been called urinary poisoning, ursemic poisoning, and urinary 
infection. 

Definition. — The febrile disturbance and accompanying 
phenomena, due to use of instruments on the urethra or blad- 
der or to surgical operations on the urinary organs, or to im- 
pressions brought to bear on the same, when the urinary or- 
gans are free from disease. 

Cases due to septic infection are not considered under this 
head, nor are cases in which some previous urinary disease 
has existed. 

Etiology. — The cases are usually due to the passage of a 
sound, or catheter, but have been known to follow even the 
insertion of a bougie. They occur, however, very rarely. 
Many surgeons have never seen a case of this disease. 

Velpeau reported some cases in 1873 an< ^ Keyes has seen a 
number of them. 

Pathology. — The writer's theory of these cases is as fol- 
lows: In considering the various phenomena which may re- 
sult from even the gentle passage of a smooth sound through 



520 DISEASES OF THE URETHRA. 

the urethra, we must remember, first, that the penis is essen- 
tially a sexual organ, having a large and readily excitable 
nerve supply, hence easily susceptible to shock, with its re- 
sultant partial arrest of the heart's action, occasioning a cor- 
responding failure in the circulation of the brain, and thus 
producing unconsciousness for a short time. This explains 
why men sometimes faint after the passage of the sound. 

Second, it must be borne in mind that the kidneys are pe- 
culiarly susceptible to any violence done to the urethra, and 
a shock to the nervous system, due to the extreme excitabil- 
ity of the urethral nerve-supply, will result in a greater im- 
pairment of the nerve-supply to the kidneys than to other 
organs, and will cause a disturbance of the vascular supply 
of the kidneys, and usually an acute congestion of these 
organs. Now in kidneys previously nephritic an acute con- 
gestion may indeed cause death from acute uraemia, superven- 
ing on chronic, in a short time. But in those cases of ure- 
thral fever, where the kidneys are not previously nephritic, 
it is difficult to understand why death from suppression takes 
place so rapidly, for, according to Bouchard, the average man 
should live fifty-two hours after simple suppression of urine 
takes place, and, as is well-known, patients not having urethral 
fever sometimes live for days without passing any urine. It 
is then, in the case of previously healthy kidneys evidently 
not simply a question of suppression of urine but a more com- 
plex one. 

According to Rachford, xanthin and paraxanthin are 
present in the scanty urine of sudden and severe cases of 
acute renal hyperaemia, and it is possible that in the acute 
hyperaemia, due to urethral fever, these or other toxic agents 
are suddenly present in far greater amount in the blood than 
we know anything about. It has been observed that a hot 
bath is one ofi the best means of restoring the renal function, 
in cases of urethral fever, and that after urinating in it the pa- 
tient may recover. Similarly favorable results have been noted 



URINARY FEVER. 521 

following hypodermics of Pilocarpine i-io to 1-5 of a grain. 
So that, in some cases at least, the condition would appear to 
be one of toxaemia, not that due to urea, potassium salts, or 
other normal constituents of urine, which, when not elimi- 
nated, cause death more slowly than happens in cases of ure- 
thral fever, but rather to a sudden and unexplicable increase 
in the amount of other toxic agents in the blood, as, for ex- 
ample, the xanthin bases, caused by the shock to the nervous 
system in general, and to reflex action on the kidneys in par- 
ticular with its resultant effect on the blood. 

Fen wick believes that in all cases of total suppression fol- 
lowing passage of sounds or the catheter, all the essentials 
for the catastrophe are present but latent, and that the indi- 
vidual has been subject previously to attacks of congestion. 
Morris also believes the kidneys to be the cause of the sup- 
pression, the lesions varying from congestion through inter- 
stitial nephritis to abscess, but even supposing these ideas to 
be true, it is difficult to understand why the suppression re- 
sults so speedily in death unless some toxin in increased 
quantity is suddenly present, the nature of which we do not 
understand. 

Clinical Features. — After passing a catheter, or sound, or 
after some other manipulation on the lower urinary tract, in 
from a few minutes to several hours' duration the patient is 
suddenly seized by a chill ; from that to a violent rigor ac- 
companied by vibrations of the limbs and body, chattering of 
the teeth, with a rapidity similar to that of an electric battery, 
pain in the back and limbs, cold perspiration, a sense of 
fatigue or complete exhaustion. The temperature rises rap- 
idly, from three to five degrees or more, accompanied by 
headache, injection of the conjunctiva, nausea, vomiting, 
dyspnoea and cardiac irregularity, with delirium. The pulse 
becomes rapid, hard and tense. After a time, a pronounced 
perspiration succeeds, lowering the temperature, accompanied 
with more or less relief to the patient ; pulse grows less fre- 



522 DISEASES OF THE URETHRA. 

quent and tense as the fever abates ; but the thirst still re- 
mains intense. 

In from six to twelve hours the fever subsides, leaving the 
patient in a weak condition ; in cases where there is a definite 
lesion the attack may be repeated ; otherwise the patient 
rapidly resumes his normal condition, and convalescence is es- 
tablished in a few days. (Harbour.) 

Suppression of urine may take place with convulsions and 
death in from six to forty-eight hours. If the urine is not 
suppressed, there is deficiency of urea, more or less blood, 
albumin, which is sometimes abundant, and in severe cases 
casts as well. 

Treatment. — The patient should at once be put into a hot 
bath and a hypodermic of Pilocarpine hydrochlorate, one- 
tenth of a grain administered. The fact that patients thus 
treated have been known to recover, after urinating and per- 
spiring freely, gives color to the writer's theory that a special 
toxaemia is the cause of the rare cases in which severe symp- 
toms take place in healthy subjects, shock being the exciting 
cause. 

Stimulants may be necessary and cupping of the loins. It 
might be that the normal salt solution would be useful in 
these cases. 



CHAPTER XIX. 



ENURESIS. 



Synonym. — Incontinence of urine. 

Definition. — Involuntary passage of urine, especially in 
children. 

Etiology. — The causes are obscure. There is probably 
either a congenitally weak sphincter or an abnormally irri- 
table detrusor. 

In some cases the child is neurotic, of epileptic parents or 
ancestry, or it may occur as a symptom of organic nervous 
disease, as epilepsy. It may be the result of defective moral 
education, indolence, lack of conveniences for urinating, in- 
digestible meals at night, the eating of too much fruit or the 
drinking of beer. Worms may cause it by reflex disturbance. 
In asylums it results from imitation. 

Townsend's classification of the causes with some addi- 
tions by the writer is as follows : 

I. Reflex. 

(i) Increased quantity of urine : 
(a) diabetes, (fr) nephritis. 

(2) Irritant quality of urine : 

(a) increased acidity, (d) uric acid crystals, (c) calcic 
oxalate crystals, (d) excess of phosphates. 

(3) Vesical calculus. 

(4) Hypersensitive state of external genitals from : 

(a) small meatus or stricture of urethra, (&) phimosis, (c) 
balanitis or vulvitis, (d) adherent prepuce and clitoris. 

(5) Anal irritation from : 

{a) pin-worms, (b) fissures, (c) eczema, (d) vegetations. 

(6) Psychical. 



524 ENURESIS. 

(7) Increased irritability of bladder. 

II. Atony of sphincter vesicae. 

(1) General debility. 

(2) Spinal disease. 

(3) Acute febrile disease. 

III. Malformations of bladder or urethra. 

To I. 4 may be added, hypersensitive conditions of the ex- 
ternal genitals due to inflammation of the vagina, vestibule, 
and urethra, caused by masturbation. Small polypous excres- 
cences about the meatus urinarius in girls. 

Among the above small ureters, a small bladder and hy- 
pospadias are organic causes. Central lesion of the brain and 
cord may also be the cause. 

Occurrence. — The condition is pathological between the 
years of four and ten, or even more. 

Nocturnal enuresis usually occurs in the first hours after 
the patient goes to sleep, but it may happen later, or even 
toward morning. 

Incontinence of urine may be either nocturnal or di- 
urnal. It may be noticed in old people and sometimes in ad- 
vanced cases of diseases of the kidneys, or in diabetes. 

The patient is usually a pallid, excitable child. 

Diagnosis. — Inability to retain the urine, which passes in- 
voluntarily, either by night during sleep or in the daytime. 

Course. — Some cases may yield to carefully conducted and 
systematic treatment. As a rule, the condition wears off when 
the patient arrives at puberty. The mental effect, however, 
on the child is depressing and effort should always be made 
to overcome the trouble. It usually subsides after the twelfth 
year of life. 

Effects. — These are chiefly mental. The patient is likely 
to become worried and depressed. In some instances suicide 
has resulted. 

Examination of the Patient. — 1. Examine the rectum ; 
look for pin-worms, fissure, eczema ; constipation to be in- 
quired into. 



ENURESIS. 525 

2. Examine the external genitals ; look for sensitive clitoris, 
tight prepuce, narrow meatus. 

3. Watch the child for masturbation. Look for balanitis, 
vulvitis, stricture of the urethra, urethritis, sensitive urethra, 
excrescences about the meatus urinarius in girls. Vaginal 
catarrh must not be forgotten. Possibility of retention in the 
bladder should not be overlooked. 

4. In case nothing can be found by examination as above 
collect the twenty-four hours' urine, examine it, and also 
a freshly-voided specimen ; the night urine may be saved 
either by the devices already mentioned in case of young 
children, or by use of a rubber urinal in older ones. 

The points to be sought for in the examination of urine are 
presence of cystitis, pyelitis, nephritis, or diabetes ; or, if 
these are absent, effort should be made to ascertain 
whether or not there is increased acidity, whether uric acid 
crystals, calcic oxalate, triple phosphate, or even simple phos- 
phates (earthy) are present. 

5. If the condition of the urine shows nothing, look for 
malformations of the urethra and bladder, and for stone in the 
bladder. 

6. Still further, if nothing thus far has been found as a 
cause, consider muscular weakness of the bladder due to gen- 
eral debility, anaemia ; inquire for history of recent severe 
illness, as* typhoid. Investigate the possibility of spinal dis- 
ease; and look carefully for slight palsies. Nocturnal epi- 
lepsy must not be forgotten, and mouth-breathing looked 
after. 

7. Even if no signs of uricsemia be present in the urine, 
examine patient for presence of tonsilitis or pharyngeal irri- 
tation, and, if found, examine urine frequently for evidences of 
uricaemia, especially that voided after over-fatigue at play. 

8. Next inquire for psychical causes ; ask the child if he 
dreams that he wants to urinate, or that he is urinating. 
Observe whether the child is intensely somnolent, unbal- 



526 ENURESIS. 

anced, etc., etc. Ascertain whether periodicity of inconti- 
nence is a marked feature ; if so, the case is of nervous 
origin. 

Treatment. — The cause must be ascertained, but in chil- 
dren the following is, as a rule, of help : Cool sponge-bath, 
with tablespoonful of sea salt added to the water, every morn- 
ing. Body briskly rubbed, and especially in the region of 
the spine, with a moderately coarse towel. Child to be clad 
in woolens next to skin and to have warm shoes ; it should 
have as much fresh air as possible in fine weather and be al- 
lowed to exercise. But very little meat should be allowed, 
and the quantity of drink should be restricted, in the latter part 
of the day especially, no fluid being given after 4 or 5 o'clock 
in the afternoon. The child should empty the bladder before 
going to sleep and should be taken up to urinate late at night 
and early in the morning ; if necessary, once also during the 
night, in each case being thoroughly awakened. 

The patient should not be too warmly covered while in bed 
nor should he lie on his back. If necessary, a brush can be 
tied to the back so that the patient may be roused when he 
turns over. If possible, he should lie with the hips elevated 
and the head low. 

An admirable rule is that the bowels be thoroughly 
cleansed by an enema shortly before bed time. 

The evening meal should be taken two hours before bed 
time. The child should avoid liquids, potatoes, and heavy 
indigestible foods. 

The bed should be provided with a firm mattress. In 
awakening the child to urinate, it is a good plan to observe 
regular hours, namely, at 10, 12, and 3. 

The child should be impressed with the idea that he must 
not wet the bed, but corporal punishment is not to be allowed. 

Rubbing the body with cold water before bed-time is often 
of service. 

Electricity is said to do good in some cases. It may be ap- 



ENURESIS. 527 

plied as follows: A broad anode is placed over the lumbar 
region of the spinal cord and a smaller kathode over the 
bladder or perineum ; a quite strong constant current is al- 
lowed to pass for two or three minutes, after which pass the 
wire end of one conducting cord, which we can make the 
kathode, into the mouth of the urethra for one or two centi- 
meters, while we place the other broad electrode on the per- 
ineum, or above the symphysis, and allow quite a strong or 
even somewhat painful faradic current act for a minute or 
two. This should be done once daily at first. 

Dilatation of the posterior urethra, by means of large 
bougies, is sometimes a successful measure. 

Symptomatic Treatment. — In this disorder the high po- 
tency men cure with Ignatia, Causticum, Pulsatilla or Sulphur 
in the thirtieth or upwards. Other remedies are as follows: 

Cina. — The urine is turbid, abundant and contains an in- 
creased amount of urea. There is a feeling of constriction 
about the loins and a bruised feeling in the small of the 
back, not worse on motion. There may be restless sleep with 
rolling of the eyes a.nd symptoms referable to presence of 
worms. 

(Use tincture in one to five drop doses.) 

Agaricus, Cimicifuga, Equisetum, Gelsemium, Hyoscyamus, 
Nnx vomica, Pulsatilla, Rhus tox., Terebinth, Stramonium, 
Santonine and Triticum repens are also used. 

Cina in the tincture, dose, five drops or even more, three 
or four times daily, may help the case when the usual indica- 
tions for the remedy are present, as when the trouble is trace- 
able to worms. Causticum, Sulphur, Aconite, Ignatia, Ben- 
zoic acid, Ferrum phos., Lycopodium, and Staphysagria are 
recommended by various writers. 

Palliative Treatment. — The principal remedies are Rhus 
aromatica, Belladonna and Strychnine. 

Rhics aromatica is given when the case would appear to be 
due to lack of tone in the sphincter due to general debility, 



528 ENURESIS. 

especially in nocturnal incontinence of urine in children. 
Dose, from 4 to 10 drops of the fluid extract four times daily, 
gradually increased to from 8 to 20 or 30, according to age of 
child. May be given in a little sweetened water. Or, chil- 
dren 2 to 6 years old may take 10 drops night and morning ; 
other children, 15 drops in the afternoon and again before 
bed-time. 

In one of the writer's cases 30 drops of the fluid extract 
taken at one dose before bedtime would always prevent enu- 
resis, but, if the remedy was omitted, the child wet the bed. 

Belladonna is given when there is irritability of the blad- 
der, in 10- to 20 -drop doses of the tincture, or Atropine sul- 
phate, one grain in an ounce of water, given in doses of one 
drop for each year of the child, at 4 and at 7, evenings, so as 
to have pupils dilated during hours of sleep. The dose at 
bedtime need not be given, if the child's pupils are well dilated. 
(Baruch.) 

There are those who claim success from Belladonna and 
the Bromides in cases where Belladonna alone fails. 

In the case of small, feeble children great care must be 
taken in giving Atropine. 

Belladonna plasters over the region of the kidneys may be 
used ; one plaster may be cut in two and half placed over the 
region of each kidney and worn for several days. 

Strychnine is given together with Belladonna when there is 
diurnal enuresis, three or four times daily. 

Various other remedies are recommended, as follows : 

Rhus tox. has long been used. 

Equisetum, Eupatorium purpureum, Pulsatilla and Gel- 
se?niuni are credited with cures. 

Liquor ferri muriatici is recommended ; two drops in a 
wineglassful of water, tablespoonful every three hours during 
the day for ansemic children. 

Ergot and electricity are used in cases of atony of the 
sphincter. 



ENURESIS. 529 

White uses the following for incontinence : . 

I*. Sodii benzoatis, 

Sodii salicylates, aagr.xx. 

Fl. ext. belladonnse, gtt. ij. 

Aquae cinnamomi, giv. 

M. Sig. A teaspoonful four or five times daily. 

Hypnosis with suggestion has relieved some cases. 

According to Barbour a combination of Boric acid and 
Salol is by far the most efficient remedy. 
t Surgical treatment may be necessary to relieve tight pre- 
puce, hooded clitoris, narrow meatus, etc. 

The passage of cold steel sounds is said to be curative in 
some cases in young boys, especially in those who mastur- 
bate. 

According to Lydston, of Chicago, the urethral sound is 
one of the most valuable measures for the treatment of a large 
proportion of cases of involuntary micturition in children. It 
acts in three ways: First, by blunting the sensibility of the 
nervous supply of the vesical neck, thus correcting hyperses- 
thesia ; secondly, by decongesting the mucous membrane of 
the deep urethra, i. e., the vesical neck ; thirdly, in cases of a 
purely neurotic type, it stimulates the relaxed sphincter 
vesicae to contract, and, so to speak, exercises it. The resent- 
ment which the muscle offers to the entrance of the sound 
produces a stimulation of nutrition of the muscle, increases its 
bulk, and adds to its tonicity, thus enabling it to resist with 
more success the egress of urine. 

The removal of hyperplasias from the nose, of phimosis 
and villous growths from the urethra should be undertaken. 



34 



CHAPTER XX. 

GLYCOSURIA AND DIABETES MELUTUS. DIABETES INSIPIDUS. 

We use the term glycosuria or melituria to describe a more 
or less temporary condition, in which sugar appears in the 
urine under varied circumstances. If the amount of sugar 
is slight and it soon disappears, the condition may be merely 
glycosuria. It is noticed (i) in healthy persons after excess- 
ive indulgence in sugar ; 200 gm. (seven ounces) or upwards 
at one time of grape sugar, in solution, may cause the appear- 
ance in an honr or two of a small amount of dextrose in the 
urine (alimentary glycosuria). If sugar appear in the urine 
after taking small amounts, as 50 to 100 gm. (two to three 
ounces) the condition is called morbid alimentary glycosuria. 
The writer has observed this condition occur in patients after 
taking certain articles of food or drink, notably, bananas and 
champagne. In such cases the power to assimilate sugar is 
subnormal and the condition maybe followed in time by true 
diabetes mellitus. The writer has found that the best time 
for the detection of morbid alimentary glycosuria is in the 
afternoon, the saccharine articles being taken at lunch. 

Such a glycosuria is observed according to Strumpel in 
obese beer drinkers, in patients with severe traumatic neurosis, 
and in exophthalmic goitre. Temporary glycosuria may 
occur in acute infectious diseases (typhoid, scarlet fever, 
diphtheria, malaria, cholera, malignant pustule,) in nervous 
disturbances as from injuries to the head, in diseases of the 
brain, and after epileptic fits, after the administration of drugs 
in toxic doses as Curare, Amyl nitrite, Mercury, Morphine, 
Hydrocyanic acid, in poisoning by Carbonic oxide, and after 
ingestion of Phloridzin, in the latter case without general 
disturbance, and after the injection of Supra-renal extract. 



DIABETES MELLITUS. 531 

Inasmuch as the causes of temporary glycosuria mentioned 
above may also in some cases occasion a true chronic diabetes 
mellitus, care must be taken not to regard the condition as 
unimportant. In the writer's experience temporary glycosuria 
is a comparatively rare condition. 

DIABETES MEEEITUS. 

Definition. — A chronic disease characterized by persistent 
presence of dextrose in the urine, and in severe cases by 
polyuria, polydipsia, digestive disturbances, and progressive 
loss of flesh and strength. 

Etiology. — The causes of diabetes mellitus are said to be 
as follows : 

i. Heredity, as in members of the same family. 

2. Syphilis or syphilitic parentage (rarely). 

3. Gout or gouty ancestry and general arterio-sclerosis. 

4. Nervous shocks and strains ; various nerve injuries and 
nervous diseases. 

5. Acute infectious diseases (occasionally) and exposure to 
cold. 

6. Diseases of the pancreas and liver. 

7. Improper dietary ; long continued indulgence in sweets ; 
sedentary life and over-eating. Excessive beer-drinking, or 
drinking of cold fluids. 

8. Emotional disturbances, as shock of bereavement, etc. 

9. The causes of temporary glycosuria mentioned above. 
Of the diseases of the pancreas, concrements in the ducts is 

the principal one ; of the liver, traumatism, congestion, and 
cirrhosis. 

Diabetes mellitus in children has been known to follow 
typhoid fever and purpura hemorrhagica. 

Stern saw one case in which the children were seemingly 
born with diabetes mellitus. 

Drummond reports a case in a boy of seven who died of 



532 DIABETES MELLITUS. 

diabetic coma five months after receiving a blow on the 
head. 

Diabetes mellitus may be the chief symptom of cerebral 
syphilis or other lesion encroaching on the medulla. 

Falls, blows, railway accidents and violent mechanical agi- 
tation of the nervous system are known to cause diabetes. 

The disease may alternate in families with central neuroses 
(hysteria, neurasthenia and epilepsy) or mental disorders. 

In cases of diabetes due to injury there is probably some 
peculiarity in the individual. 

Obesity is a forerunner of diabetes in some cases, but the 
exact relation has not been determined. 

In a few cases influenza appears to play some part as an 
exciting cause. 

A case is reported due to lightning stroke. 

It is possible that pregnancy, the puerperal state, or the 
condition of the breast may be exciting causes ; the climacteric 
may also, possibly, be an exciting cause. 

Diabetes mellitus is occasionally closely related to in- 
sipidus. 

Pathological anatomy alone does not furnish any clear evi- 
dence that diabetes is related to hepatic changes. 

Emotional disturbances apparently play some part as excit- 
ing causes. It is quite possible that some slight functional 
change in the medulla may be the cause or play some im- 
portant part in causation of certain cases. 

In a considerable number of cases of diabetes where the 
pancreas has been studied post-mortem it seems probable that 
the diabetes was either due to some other cause than pancre- 
atic lesion, or to some functional or vasomotor change in the 
pancreas. 

In a smaller number it appears probable that the pancreatic 
disease was the cause of the diabetes. 

It is conceivable that arterio-sclerosis may cause diabetes 
by producing changes in the pancreas or in the medulla. 



ETIOLOGY OF DIABETES MELLITUS. 533 

In one hundred consecutive cases of diabetes Williamson 
found a history of alcoholic excess in 17 cases, no definite 
history in 15, heredity in 13, emotional disturbance in 10, 
anxiety and worry in 8, influenza in 8, sudden onset of thirst 
in 9, pregnancy, etc., in 7, external injury in 6, overwork in 
5, syphilis in 6, obesity in 4, nasal catarrh and bronchitis in 
3, pleurisy in 2, pneumonia in 1, acromegaly in 2. 

Osier thinks that intense application to business, over- 
indulgence in food and drink and a sedentary life are con- 
ducive to it. 

In children it is usually due to hereditary influences or in- 
juries, or develops during convalescence from severe acute in- 
fectious diseases. 

In adults those who are obese, gouty, and subject to gall- 
stones or renal calculi are more liable to it. 

It is said that a family history of tuberculosis is frequently 
met with in diabetics. Considering, however, that family 
history of tuberculosis is, especially in New England and in 
other parts of the world, common to many who never have 
diabetes, the writer thinks it more likely a coincidence than 
an etiological factor. 

Gastric catarrh is mentioned in connection with the eti- 
ology, but, since the connection of gastro-intestinal troubles 
with the prodromata of diabetes has been discovered, it is 
possible that this disorder is an early manifestation rather 
than a cause. 

According to John A. L,arrabee diabetes is connected with 
inherited neurotic tendencies. Epileptic, nervous, or hysteri- 
cal parents are responsible, he thinks, for the diabetic diathesis 
in children. 

Mild cases may become more severe under the influence of 
traumatism. It, therefore, becomes of interest to determine 
whether the advent of the disease is hastened by trauma in a 
patient presumably in the prodromal stage. 

L/Oomis speaks of a female child, twelve years of age, who> 



534 DIABETES MELLITUS. 

after fourteen months' illness from nephritis, coming on eigh- 
teen months after scarlet fever, suddenly died of diabetic 
coma. 

Transient glycosuria in children has been noticed following 
a number of conditions ; malaria, measles, immoderate and 
also indiscriminate eating ; daily exposure to wet and cold. 

The writer finds that in all his cases but one there was a 
history of fondness for sweets and indulgence in them. 

According to Haas, of New York, there is a possible etiologic 
connection between peliosis rheumatica and diabetes. He re- 
ports two cases in children, aged five and nine years re- 
spectively : 

The two cases occurred in children who were members of 
the same family. The father and grandfather and an aunt on 
the paternal side, as well as the maternal grandmother, had 
tuberculosis. No diabetes had occurred in any other mem- 
ber of the family. The first was a combination of peliosis 
rheumatica and diabetes, and exhibited the symptoms of the 
rheumatoid condition, the purpuric eruption, etc., together 
with glycosuria. The former disappeared after a week, and 
the girl was doing well at last report. The second case oc- 
curred in a boy who had sustained severe injuries eighteen 
months before, but unfortunately the exact nature of this in- 
jury could not be determined from anamnesis, otherwise a 
clue as to its etiologic significance might have been obtained. 

According to Leese heredity is of some importance as a 
cause of diabetes, and is often limited to one line or side of 
the family ; but the disease does not seem to be conveyed 
from one person to another, even when living in the most in- 
timate relations. Cases where both husband and wife are 
affected are due rather to both parties being subject to the 
same diet and living under like conditions, and having similar 
cares of life. Diabetes is more rare in women than in men. 
It is least frequent before puberty, increasing during the child- 
bearing period, and diminishes again in old age. Obesity from 



ETIOLOGY OF DIABETES MELLITUS. 535 

high living and a sedentary life predispose to diabetes, which 
has been termed constitutional diabetes, and is more common 
in women, in contrast to neurogenous or accidental diabetes 
occurring after injuries or alterations of the nerves, which oc- 
curs more often in men. 

Occurrence. — Adults between thirty and sixty are more 
subject than children, and men than women. Fat persons 
are more subject to it than lean, and it is a disorder of consid- 
erable frequency among Jews and Hindus. 

The writer thinks diabetes mellitus in children to be fairly 
common in the West as compared with certain other locali- 
ties. Out of a total of 226 cases of diabetes which the writer 
has seen, 26 were children, while Prout out of 700 saw only 
about a dozen in children, and Schmitz (presumably a Ger- 
man authority) out of 2 115 cases in all saw only 85 under 
twenty years of age, while only 10 of these were under ten 
years of age. 

Cases are common in the same family. The writer knows 
a family which has lost three children in succession of dia- 
betes millitus. Isenflam reports a case in which eight chil- 
dren of healthy parents all died of diabetes mellitus after 
reaching their eighth year. 

Female children are said to be more susceptible to diabetes 
mellitus than males. 

Diabetes mellitus is rare in children under five years. 

Locomotive engineers show seven times as great mortality 
from diabetes in America as others. 

Diabetes is said to be common among Wall Street men. 

It is common in certain countries and districts as in India, 
Ceylon, Italy, Malta, Normandy and the cities of France. 

The disease is more rare in America than in Europe, the 
mortality here being 2.8 in 100,000 of the population, while 
in Europe it is from 5 to 9, but it is increasing in America 
apparently with the increase in extravagant or luxurious 
living. In the colder parts of the United States the higher 



536 DIABETES MELLITUS. 

mortality is found in the rural districts, while in warmer 
parts it is higher in the cities. American Indians and China- 
men in the United States are free from it. It is uncommon 
in negroes. The disease is commoner among well-to-do 
people than among the poor by ten times. 

Husband and wife may have the disease, but it is probably 
accidental in such cases, or due to similar conditions of life. 

It is said that more cases develop in March, April, July 
and November than in other months. 

Those of neurotic temperament are more subject to it than 
others. 

Pathology. — An excess of sugar in the blood may result 
from the following causes : 

i. Increased supply in the diet. 

2. Failure on part of the body to decompose or store that 
which is introduced, due (a) to disturbances of the portal cir- 
culation, or (d) disturbances in the function of the liver. 
Faulty innervation may be the cause of the disturbances in 
the portal circulation, and the functional hepatic disturbances 
may bring it about that either more glucose enters the blood 
without being transformed into glycogen in the liver or an 
excessive transformation of glycogen in the liver takes 
place, setting free an excessive amount of sugar. 

Pavy's idea of diabetes is that the whole trouble is due to 
imperfect de-arterialized venous blood, consequent upon vaso- 
motor paralysis, especially of the vessels of the chylo-poietic 
system. 

Larrabee thinks there is changed polarity of the nervous 
system without observable lesion. 

The opinion is gradually gaining ground that diabetes is 
not a pathological entity, but rather a group of symptoms 
which may be produced by various mcrbid changes in the 
system. Sometimes the starting point is in the nervous sys- 
tem, sometimes in the pancreas, occasionally in arterio- 
sclerosis, possibly in the muscles sometimes and possibly it is 



PATHOLOGY OF DIABETES MELLITUS. 537 

due to various other causes and to endogenous or inherited 
morbid conditions. (Williamson.) 

According to Flexner, although the pancreas has been 
shown to influence and regulate carbo-hydrate metabolism, it 
is by no means proven that the cause of diabetes is always 
resident within that organ. The complete removal of the 
pancreas in animals is always followed by a diabetes of severe 
type, yet it can be removed in part, and not necessarily be 
followed by diabetic symptoms. The amount of the gland 
left behind should be at least one-fifth. It is also known 
that the diabetes resulting from the extirpation of the pan- 
creas is fatal. Of the causes of the pathological changes in 
the pancreas, the chief one is supplied by concrements in the 
ducts. 

That diabetes can result from disease of the liver seems 
probable, as that condition has been observed following trau- 
matism, as an accompaniment of cirrhosis and congestion. 

Pathological conditions of the central nervous system and 
the peripheral nerves may cause diabetes and glycosuria. 
What the relation of the central nervous system and the 
organs of the carbo-hydrate metabolism is we are not in- 
formed. Naunyn states : " I hold it as proven that diseases 
of the nervous system lead to diabetes, in that there occur 
coincidently disturbances of function in other organs which 
preside over the carbo-hydrate metabolism ; that these dis- 
turbances are not simple expressions of the abnormal func- 
tional activity of the central organs ; but, using the analogy 
of the motor in contra-distinction to the nutritive or secretory 
neuron, we can imagine that each stands for an entity, the 
one acting on the muscle cell (motor neuron) and the other 
upon secretory cells, as in the liver and pancreas (secretory or 
nutritive neuron). And just as diseases of the motor neuron 
in any part set up pathological changes in the entire system, 
so may the secretory organic cells be influenced injuriously 
in such ways as to give rise to diabetes, because of their con- 



538 DIABETES MELLITUS. 

nection with diseased nervous structures with which they in- 
dissolubly unite, and under whose domination they are." The 
existence of the renal form of diabetes is yet unproven. 

Post-Mortem Appearances. — The post-mortem appearances 
show the following : 

i. In many cases no lesions at all. 

2. In some cases lesions of pancreas and tissues in its 
vicinity. 

3. Hypertrophy of the liver, in some cases no change. 

4. Enlargement of the kidneys with injection and presence 
of glycogen in Henle's tubes near the bases of the pyramids, 
with also, at times, fatty degeneration of tubular epithelium. 

5. Evidences of tuberculosis of the lungs and other changes 
in them. 

6. In a case reported by Joseph B. Betts autopsy showed 
amongst other things atrophy of the head of the pancreas. 

The pancreas showed moderate interacinar cirrhosis. The 
islands of Langerhans were normal in number, but many were 
not clearly defined, and some were surrounded by a distinct 
connective tissue capsule, which separated them into little 
lobules. In the bodies themselves were many cirrhotic 
islands, some of them apparently degenerating in their central 
portion. The head of the pancreas was loose in structure, 
and in some lobules the secreting acini were atrophied. The 
islands were scarce and were surrounded by thick fibrous cap- 
sules, and were separated into lobules by thick bands, evi- 
dently the thickened capillaries of the island. Bands of 
fibrous tissue extended outward between the acini. In sec- 
tions from the head of the pancreas no islands could be found, 
and in some parts the cells seemed to be degenerating. 
Throughout the pancreas the larger vessels showed decided 
arteriosclerosis and venous congestion. The cirrhosis was of 
the interacinar type, and, as a rule, was most marked in the 
immediate vicinity of the islands of Langerhans, although in 
some sections it appeared to extend from the thickened walls 
of the ducts. 



PATHOLOGY OF DIABETES MELLITUS. 539 

7. Frerichs has demonstrated by means of the microscope 
lesions of the medulla oblongata in frequent instances, but 
the changes enumerated by him are not always present and 
their significance is doubtful. 

The condition of the kidneys and of the lungs above de- 
scribed is due to organic diseases which are merely complica- 
tions, so that on the whole the pathological changes are 
trifling. Modern study is being directed more and more to 
the pancreas and to hyaline degeneration of the islands of 
Langerhans in it. According to Anders, the pancreas shows 
morbid changes in fifty per cent, of the cases. 

Onset. — There are those who manifest a tendency to dia- 
betes by various symptoms, especially by the occurrence of 
transient glycasuria usually in the afternoon. Stern claims 
that the prodromic stage of diabetes mellitus is characterized 
by the following : 

1. Gastro-intestinal disturbances, intolerance of carbo- 
hydrates and occasionally of hydrocarbons, hyperchlorhy- 
dria, gastiocholia, hepatico-pancreatic disturbances. 

2. Sickening pain in the epigastric region, increasing after 
eating and upon pressure ; dull pain in right hypochondriac 
region ; sometimes a feeling of tension around the umbilicus. 

3. Polysarcia, the obesity disappearing as dextrose is 
eliminated ; no excessive appetite or thirst. 

4. Diminution of sexual inclination ; great nervous irri- 
tability and occasional hypochondriasis when there are con- 
comitant genito-urinary neuroses ; no emaciation, if no 
diathesis is present in the individual other than the diabetic. 

5. Disorders of the cutaneous surface ; dermatalgia ; dimi- 
nution or suppression of perspiration and transpiration ; over- 
loading of the blood with carbon dioxide. 

Stern holds that urine of the preglycosuric stage is quite 
normal, barring an occasional azoturia. In this the writer's 
experience does not coincide with that of Dr. Stern. 

I have seen several cases which later became diabetic. In 



540 DIABETES MELLITUS. 

not one of these cases could the urine, when first examined, 
be deemed normal in all respects. Two cases were apparently 
those of chronic interstitial nephritis, one was lithuria, sev- 
eral others had deposits of uric acid or calcium oxalate, with 
casts and a plain trace of albumin in the urine. 

The writer's method of early recognition of the diabetic 
diathesis is to examine the urine of every micturition of the 
twenty-four hours separately. Sugar, recognizable by Haines' 
test-liquid, will be found at some one hour of the day — in the 
writer's experience most commonly after the digestion of the 
noonday meal, i. e., about 3 o'clock in the afternoon. The 
symptoms that Stern speaks of may or may not be present, 
and sugar may occur with but few or none of Stern's symp- 
toms except increase in weight, due to fat, which the writer 
believes is often significant. 

In general, then, when a person who has become fat pre- 
sents himself for examination the writer deems it wise to 
make separate tests of the urine of every urination of the 
twenty-four hours. Sugar will often be found in the urine 
voided two hours after the noonday meal. If it is not found, 
cause the patient to drink champagne, or eat cheap candy 
or 100 grammes of glucose, and test the urine the same day 
and next morning. If there is a glycosuric tendency, sugar 
will be found in the urine of one or more urinations. 

Even if no sugar be found by these methods, but the pa- 
tient, having become obese, voids urine containing albumin 
in small quantity and perhaps casts, or sediments of uric acid 
and urates or oxalate of lime, the case is a suspicious one. 
If, in addition to this, he also has a family history of diabetes 
mellitus and exhibits the succession of symptoms described 
by Stern, the case is, no doubt, in the prodromic stage of dia- 
betic degeneration. 

There are some persons who void an unusual amount 
(above 500 grains) of urea and of uric acid (above 10 grains) 
before the appearance of sugar. But while this is always sus- 






DIAGNOSIS OF DIABETES MELLITUS. 541 

picious (since fat people do not by any means normally void 
solids in proportion to their weight), it is not invariable. (It 
is quite common, however, in cases in which sugar has disap- 
peared from the urine and albumin taken its place, the pa- 
tient becoming nephritic ; hence the physician is often puz- 
zled to account for the condition of the urine as regards solids 
in what is evidently a case of chronic Bright's disease. The 
writer will illustrate by means of analyses of urine farther 
on.) 

A peculiarity which the writer has noticed in two of the 
preglycosuric cases was that the small amount of albumin 
present was not reduced in the slightest degree by avoidance 
of meat, but remained in about the same bulk, regardless of 
diet. 

The writer believes that a slight albuminuria and cylindruria 
in stout persons is possibly due to arterio-sclerosis, a forerun- 
ner of diabetes mellitus, which is, perhaps, not unfrequently 
hastened in its development by non-nitrogenous diet, which 
does not at the same time exclude sweets. 

When diabetes mellitus itself appears there may be at first 
merely languor, loss of flesh, weakness and lack of endur- 
ance ; or slight nervous disturbances, including headache, 
mental depression, wakefulness and neuralgia ; in other cases 
gastro-intestinal symptoms, including nausea, eructations and 
irregularity of the bowels. Soon, however, the changes in 
the urine appear and a train of symptoms. 

In some cases cramps in the calves of the legs or sudden 
thirst is the first symptom. 

Diagnosis. — ; Thirst, polyuria, and the voiding of pale urine 
of specific gravity above 1024, containing sugar, establishes 
the diagnosis. 

To distinguish glucose in the urine from glycuronic acid 
and lactose, Williamson advises fermenting the urine in a 
test-tube for twenty-four hours and then applying the copper 
test, as Fehling's. Glycuronic acid and lactose do not ferment 



542 DIABETES MELLITUS. 

with yeast, hence if a slight reaction with the copper test was 
obtained before fermenting the same will be present after. 
Whereas if the slight reaction before fermenting was due to 
glucose, there will be none obtained after fermentation. 

The writer uses Haines' test for sugar and has as yet not 
seen a reaction with it which was referable to glycuronic acid, 
though in one or two cases a reaction has been obtained due 
to lactose. The orcin test for glycuronic acid should also 
be tried. 

Eichhorst says " the single trustworthy symptom is the 
presence of sugar in the urine " which, if found, requires ex- 
planation as regards cause, etc., whether the case is merely 
one of symptomatic glycosuria or true diabetes mellitus. 

Suspicions symptoms are languor and debility, furunculosis, 
pruritus vulvae in women, balanitis in men, cataract, sciatica, 
especially if bilateral, and impotence In cases of temporary 
glycosuria, great care should be taken to assure the patient 
that diabetes mellitus is absent. In the writer's experience 
patients with temporary glycosuria are exceedingly nervous 
and inclined to worry about themselves. On the other hand 
it is often difficult to rouse the confirmed diabetic to a sense 
of the necessity of taking care of himself, which he will as a 
rule only do when he is alarmed. 

In doubtful cases administer ioo gm. of grape sugar and 
test the urine a few hours after ingestion of it. 

Williamson's blood test is an important element in the 
diagnosis of doubtful cases. (See The Blood, further on). 

Clinical Features. — Polyuria. — There are, however, some 
few cases, usually mild ones, in which the quantity of urine 
is normal or sub-normal {Diabetes Decipiens). Severe cases 
may grow milder, and the urine become normal in quantity. 
In severe cases several gallons may be voided during the 
twenty-four hours. Drenching sweats may alternate with 
polyuria. 

Thirst. — Usually in proportion to the percentage of sugar 



SYMPTOMS OF DIABETES MELLITUS. 543 

or quantity of urine. May be so severe that trie patient is 
unable to be away from the vicinity of drinking-water either 
by day or by night. 

In some cases thirst is not at all a marked feature, though 
more or less dryness of the mouth is usually noticed by the 
patient. 

In the case of children thirst is usually a marked feature. 
Bichhorst mentions cases where children have drunk their 
own urine when unable to obtain water. 

Hunger and Emaciation. — More marked in lean patients, 
and unrelieved even by large quantities of food. 

In mild cases the patient may merely testify toa " good 
appetite " and the loss of flesh be temporary and recovered 
from under treatment. 

Osier mentions a case of the severe form in which hunger 
was so extreme in a man that he was paid to stay away from 
hotels where table d' hote dinners were served. 

Sugar in the Urine. — See remarks on the Urine. 

Other Constitutional Symptoms. — In mild cases we find 
merely slight weakness on exertion. In severe cases great 
weakness, mental irritability and depression, and indisposi- 
tion to mental effort. The bodily temperature is normal or 
slightly subnormal. 

Gastrointestinal Symptoms. — Thirst and hunger have al- 
ready been mentioned. 

The tongue and mouth are dry. The former is broad, thick, 
sometimes of an irregular fissured surface and either coated 
or red. 

Spongy, easily bleeding gums, and loose, carious teeth are 
noticed. White patches may be seen on the gums and soft 
palate. 

The writer has observed in many cases that diabetics in 
talking manifest a peculiar " click," due to the condition of 
the tongue and the dry mouth. The saliva is acid and in 
severe cases thrush may form on the soft palate. 



544 DIABETES MELLITUS. 

Constipation is very common in the cases when the red 
reaction with ferric chlorid is found. When relieved, it may 
cause disappearance of the reaction. 

The symptoms of diabetes may be referred by a patient 
ignorant of the presence of the disease to the alimentary tract ; 
there may be in severe cases gastric crises much like those of 
tabes, paroxysmal pains mistaken for gastralgia, constipa- 
tion and even loss of appetite. 

Obstinate constipation frequently precedes coma. 

Gastric symptoms are absent until the last stage, or when 
the red reaction appears with ferric chlorid. Rigid diet may 
sometimes cause gastric catarrh. 

Constipation is very common. 

Diarrhoea may be severe, but at times only in earlier stages. 
It is a serious symptom. 

The liver may be somewhat enlarged. Jaundice is com- 
mon, but usually due to some complication. 

Gastric crises (nausea, vomiting, fever, pain in the stomach 
and intestines, followed by great weakness) occur at times, 
usually, however, in the last stage, that of ethyl-diacetic acid 
poisoning. They are an unfavorable sign. 

Gastric ulcer rarely occurs. 

Dilatation of the stomach may occur, especially when the 
patient eats enormously. 

Liver and Pancreas. — Noteworthy enlargement of the liver 
is rarely detected during life. 

Gall stones may occur in obese patients. 

Cases of so-called pancreatic diabetes present the following 
in exceedingly rare cases : 

i. Tumor of the pancreas. 

2. History of severe colic. 

3. Maltose in the urine. 

4. Fatty motions without jaundice. 

5. Great quantity of nitrogenous material in the faeces. 
Respiratory Tract. — Symptoms are absent in the milder 






SYMPTOMS OF DIABETES MELLITUS. 545 

cases. In severe cases, especially in young patients, fruity 
odor of the breath, tuberculosis, pulmonary gangrene and 
croupous pneumonia occur. 

Tubercular phthisis is by far the most common lung dis- 
ease. 

Chronic pneumonia (chronic pneumonic, non-tubercular 
phthisis) rarely occurs, as also acute croupous pneumonia. 
The latter, however, . runs an acute course and is very fatal. 

Emphysema and chronic bronchitis occasionally occur. 

In diabetic pulmonary gangrene offensive expectoration 
may not be observed. 

Appearance of the Patient. — The face may appear sunken 
and wasted, the wrinkles of the face about the mouth are 
well-marked, the naso-labial fold is deep or sharply defined 
and is frequently prolonged downward. There is rarely 
anaemia or pallor. There may be a slight degree of conges- 
tion or cyanosis about the tip of the nose, cheeks, or lips and 
sometimes the conjunctivae appear abnormally moist. Patients 
are likely to look older than their years and to wear an ex- 
pression of nervousness, anxiety, or grief. In mild cases there 
is no typical facial expression. The breath of the patient 
often has a fruity odor and acetone may be detected in it 
when coma is present. 

Circulatory Symptoms. — The pulse is usually soft, except 
where general arterio-sclerosis is associated. In elderly 
patients and sometimes in young ones we may notice cardiac 
weakness and a slow pulse (50 or lower) on the one hand or 
a rapid one (100 to 120) on the other, with shortness of 
breath, faintness, etc. 

The patient occasionally may die suddenly from heart 
failure. 

In some cases Williamson has found the pulse remarkably 
hard and the tension very high, when there is no renal disease 
and the patient under middle age. 

Arterio-sclerosis is often a complication. In many cases if 
35 



546 DIABETES MELLITUS. 

three ringers are placed on the radial artery and firm pressure 
made with the finger nearest the elbow so that the pulsation 
is arrested, the artery can be rolled beneath the two fingers 
as a hard cord. 

Genito- Urinary Symptoms. — In women pruritus vulvae is 
common, due to the irritation from decomposing saccharine 
urine. Eczema or furunculosis of the genitals may occur. In 
men balanitis, phimosis, and paraphimosis occur. Impotence 
is common in men. Chronic nephritis frequently occurs as a 
complication. In such cases sugar generally diminishes in 
the urine and may even be absent. 

Pneumaturia is occasionally met with, due probably to for- 
mation of carbon dioxide from fermentation of the sugar in 
the bladder. 

The trace of albumin in the urine may result from admix- 
ture with a little pus in cases of balanitis. 

The pathological changes in the kidneys in 92 cases of 
diabetes examined post-mortem at Vienna by Kundrat 
showed parenchymatous and fatty degeneration in 24, granu- 
lar kidney in 9, hypertrophy in 4, chronic tuberculosis in 2, 
acute haemorrhagic nephritis in 1. 

Chronic interstitial nephritis is rare. It occurs almost ex- 
clusively in obese or gouty patients. 

Cutaneous Troubles. — The skin lesio7is of diabetes are very 
numerous : asteatosis, anidrosis, paresthesia xanthoma, gan- 
grene, papular urticaria, eczema, erythema, psoriasis, acne, 
dermatitis, herpes zoster, mal perforant, purpura, bronzed 
skin, bullous and pemphigoid lesions, denuvium capillorum, 
paronychia, pruritus, eczema vulvae, balanitis and balano- 
posthitis and furunculosis may occur. The patient may 
suffer from boils, carbuncles and gangrene of one or more 
toes which may take the form of perforating ulcer, or the latter 
occur independently on the feet. Erysipelas may also occur. 
If the heart is weak there may be oedema of the cellular tissue. 

Boils generally occur in stout patients and may be single or 



SYMPTOMS OF DIABETES MELLITUS. 547 

multiple. They usually develop upon the neck, back of the 
shoulders, or on the buttocks. In women they sometimes 
form on the labia of the vulva. 

As a rule they occur mostly on the neck, occasionally on the 
face or other parts. They have a tendency to extend and be- 
come gangrenous, and are often a cause of death. 

Gangrene affects the lower limbs, commencing in the toes. 
The patient develops severe symptoms, becomes drowsy and 
coma may occur. Wounds in diabetic patients heal badly 
and operation incision wounds also, as for example that for 
phimosis. But the operation for cataract is now very often 
successful. 

Bulbous fingers have been noticed by Williamson. 
Spontaneous shedding of the nails has been noticed in a few 
cases. 

Anasarca without obvious cause may occur, chiefly in the 
legs, occasionally in the hands, face and elsewhere. 

The Eye in Diabetes Mellitus. — Retinitis and muscular 
paresis are among the ocular troubles noted. All the ocular 
tissues, viz., the cornea, iris, crystalline lens, vitreous humor, 
retina and muscles may be affected, but changes in the crys- 
talline lens are the rhost common. In some cases, especially 
in children, cataract may develop with amazing rapidity, even 
in a few hours. 

In young diabetics sudden blindnesss sometimes occurs. 

Besides cataract we find pure accommodation paralysis in 
middle age, myopia in later life, vitreous opacities, retinitis, 
amblyopia, like tobacco amblyopia. The last two are very 
rare. The writer has, however, seen several cases of diabetic 
retinitis. 

Cataract is usually bilateral and does not, as a rule, disap- 
pear under diabetic treatment, though it may improve for a 
time. A case of spontaneous disappearance has been re- 
ported. 

Operation is usually successful, but occasionally has been 
followed by coma. 



548 DIABETES MELLITUS. 

Retinitis, when occurring, is almost invariably in persons 
above forty-five years of age. 

According to Williamson diabetic retinitis differs from al- 
buminuric retinitis in that there is no diffuse retinitis and 
the retinal arteries and veins are not much changed in ap- 
pearance. The haemorrhages, as a rule, are punctiform, it is 
not associated with optic neuritis, and the patches are dis- 
tributed irregularly over the central part of the retina. 

Very rarely albuminuric retinitis may occur in a diabetic 
who has contracted kidney. 

Very rarely a tumor of the brain gives rise to optic neuritis 
and glycosuria in the same patient. (Williamson.) 

Diabetic amblyopia resembles tobacco amblyopia. It is 
thought to be a retro-bulbar neuritis. 

The Ears.—Kn acute inflammation of the middle ear of 
rapid onset occurs. Abundant suppuration, with tendency to 
severe haemorrhage and early extension to the mastoid is 
noticed in diabetes, but is not common. 

The Sexual Functions. — Sexual desire and power are less- 
ened in men and in severe cases in women. In elderly women 
with a mild form of diabetes it is said to be increased. 

In some cases impotence is the first symptom noticed by 
men. It may disappear on treatment. The writer has had 
several cases who regained sexual power on dietetic treatment 
alone. 

The menstrual functions may be more or less deranged. 
Amenorrhcea is sometimes an early symptom. In pregnant 
women there is a marked tendency to abortion. 

Death of the foetus occurs in fifty per cent, of the cases. 
The disease becomes worse in the mother after confinement. 

The Nervous System — Mental depression is very common. 
Headache, mental and physical hebetude, loss of memory, 
sleeplessness, weakness of judgment and will, localized 
muscular paresis, cramps in the calves, absence of patellar re- 
flexes, neuralgia, sciatica, which may be bilateral and ob- 



SYMPTOMS OF DIABETES MELLITUS. 549 

stinate, localized cutaneous anaesthesia and coma are noticed. 

Mental excitement is known to aggravate glycosuria. 

Not infrequently the diabetic patient becomes cunning and 
deceitful in regard to minor matters. As Dickinson says, the 
mind deteriorates morally and intellectually. 

The writer knows of one case, that of an adult woman, 
who, being diabetic, died insane. 

Epilepsy and diabetes sometimes occur simultaneously. 

In a few rare cases symptoms resembling those of general 
paralysis have been met with in diabetic patients and have 
improved on diabetic diet. 

Occasionally, though very rarely, spinal cord disease may 
be the cause of diabetes, and in some cases the two seem to be 
associated. Changes in the spinal cord, the result of diabetes 
and due to some toxic agent in the blood, have been observed 
by Williamson. 

As a rule, the loss of patellar reflex is more frequently as- 
sociated with unfavorable symptoms in the patient in severe 
cases. Loss of the wrist-jerk is frequently observed in severe 
cases. Slight symptoms of neuritis, such as pain in the legs, 
cramps, numbness, tingling, tenderness and absence of knee- 
jerks are not infrequent in diabetes, but marked paresis or 
paralysis is rare. (Williamson.) 

Eichhorst mentions cases in which peripheral pseudo-tabes 
occurs, with ataxic gait, swaying of the body when the eyes 
are closed and slow pupillary reaction. 

Miscellaneous. — Stark calls attention to the following signs 
and symptoms of diabetes mellitus frequently encountered in 
middle-aged women : 

Periodic attacks of headache in obese subjects over thirty- 
five years of age ; extreme and lasting fatigue after short but 
violent exercise, and prolonged fatigue, say, of one or two 
days' duration, following slight exercise ; slowly failing vision 
in the aged or quickly failing vision in the young ; certain 
signs referable to the mouth, such as acid saliva, receding 
gums, fissured and extremely reddened tongue. 



550 DIABETES MELLITUS. 

Two varieties of symptoms are referable to the heart and 
its functions — the one set simulating an attack of angina 
pectoris and a second set presenting the physical signs of 
arteriosclerosis, or of cardiac hypertrophy. This latter set of 
cases may be met with not infrequently in obese male sub- 
jects with florid countenances and with otherwise healthy ap- 
pearances. Another train of symptoms is referable to the 
nervous system. 

In young patients the lungs and sputa must be examined 
for evidences of phthisis and in elderly ones the heart must 
be watched for signs of dilatation or other disease. 

In sucking babes loss of flesh is sometimes the first notice- 
able symptom of diabetes. 

Diabetes sometimes manifests - itself in children by bed- 
wetting. 

The Urine. — i. Polyuria is an important feature. As much 
as 19,200 c. c. (640 fl.oz.) has been noticed, but usually the 
quantity varies from 3000 c. c. to 9000 at most. In mild 
cases there may be no polyuria or even a diminished amount 
of urine (diabetes decipiens). The amount of sugar does not 
always run parallel to the amount of urine. 

The amount of urine is about equal to the amount of fluid 
taken. 

The features are the following : 

2. Persistent presence of dextrose ; in well-marked cases the 
average is four per cent. The writer has seen no higher than 
seven and a half, but ten per cent, or more has been reported. 
The largest known amount in twenty-four hours is two and 
one-fifth pounds (one kilogm). 

3. High specific gravity (due to sugar, and sometimes to 
excess of urea as well), even above 1050. Low specific gravity 
does not exclude the disease. The writer has seen one or two 
cases in which the specific gravity for a time was below 1013. 
Striimpell has seen it as low as 1007. 

4. Light lemon-yellow color, when fresh. The greenish 
tint is peculiar. 



THE URINE IN DIABETES MELLITUS. 551 

5. Increased frothiness. Acid reaction. 

6. Urine drying on black shoes leaves white specks and 
stiffens the linen. 

7. In severe cases increase of urea and phosphoric acid ; in 
a number of mild cases, however, the writer finds these sub- 
stances normal or even sub-normal in amount. 

8. Traces of albumin. In the writer's experience several 
cases of diabetes have begun with a persistent albuminuria, 
the albumin not exceeding ten per cent, bulk and disappear- 
ing to a trace when glycosuria and polyuria appeared. 

9. Peculiar fruity odor ; noticed usually in later stages. 

10. Occasional or periodic appearance of fat. 

11. Calcium oxalate crystals in sediment frequently occur. 
Also uric acid crystals sometimes in great abundance. 

12. Spores of fu ngi present in all cases as soon as the urine 
in fermenting grows more acid. A cloud may be seen at the 
top of the glass. 

13. In later stages acetone, ethly-diacetic acid, and /3-oxy- 
butyric acid, due to the disturbed oxidation of albuminous 
substances in the food and in the body. Formic acid is also 
present. 

14. In later stages, and especially before the attacks due to 
presence of ethyl-diacetic acid, the acidity of the urine in- 
creases and the sugar may decrease or even be absent. 

15. The amount of ammonia in the urine may be largely 
increased ; as much as forty-five to ninety grains may be 
present in twenty-four hours. 

t6. Oxybutyric acid may be present in large amount, as 
much as two or three ounces (50 to 100 gm.) in twenty-four 
hours. It is due to the destruction of body-albumin. 

The sugar in the urine is diminished by muscular exercise 
in well-nourished persons, but increased in those who are 
wasted ; by worry or emotional disturbance or fatigue. It is 
diminished by febrile intercurrent affections, by phthisis, 
ascites, gout, jaundice, contracting kidney, pneumonia and 
diabetic coma, and may be absent under these conditions. 



552 DIABETES MELLITUS. 

Albumin in the urine if only a trace is of no significance, 
but if in appreciable amount with casts signifies nephritis. 

Tube-casts are not found in the urine unless there is com- 
plicating nephritis until coma comes on, when a large num- 
ber of grayish granular casts appear. 

The writer deems the advent of these casts in connection 
with the ferric chlorid reaction and coma an infallible sign of 
approaching death. 

It is well to remember that hysterical women sometimes 
put sugar in their urine for purposes of deception. If cane- 
sugar is used but a slight reaction will be obtained with the 
ordinary copper tests, but if glucose or lactose are used the 
reaction will be marked. In suspected cases the specific 
gravity of the urine will doubtless be exceedingly high, unless 
the patient knows enough to add just the right amount. A 
specific gravity above 1060 should arouse suspicion. 

The Blood in Diabetes. — Diabetes mellitus is not necessarily 
associated with any diminution of the number of red cor- 
puscles. Iyeucocytosis accompanying digestion is frequently 
well marked in severe cases. 

The percentage of fat is sometimes greatly increased. 

The amount of sugar may reach as high as 0.48 per cent, 
instead of 0.04 to 0.1 per cent. 

Williamson distinguishes the blood of a diabetic from that 
of a healthy person by the decolorization of a warm alkaline 
1 in 6,000 solution of methylene blue, from blue to yellow- 
green or yellow. 

Diabetic blood gives reaction with various aniline stains, 
as Congo-red, Biebrich scarlet and Ehrlich-Biondis staining 
fluid. 

Clinical Classification. — An attempt has been made to 
classify diabetes mellitus, according to its pathology, into 
dietetic, neurotic, and pancreatic cases. This classification 
is, however, difficult to demonstrate clinically. The best 
classification is that which has long been made into mild and 



CLINICAL CLASSIFICATION OF DIABETES MELLITUS. 553 

severe cases, according to the influence of diet and the pres- 
ence of the ferric chlorid reaction in the urine. The writer 
sub-divides the mild cases into those more manageable and 
those less manageable. 

[Rare cases may occur in which features of pancreatic dis- 
ease may be present with defective assimilation of albumin 
and fats, absence of marked thirst or polyuria, presence of fat 
in the stools, etc. These cases pursue a severe and rapid 
course. The patients complain of epigastric pain and there 
may be signs of a pancreatic growth.] 

In the milder cases exclusion of carbohydrates from the diet 
is followed by the disappearance of sugar from the urine in 
from one to three days ; in the less mild cases it may require 
fourteen days ; in serious cases it may never wholly disap- 
pear. 

Williamson distinguishes two chief forms — the severe, in 
which thirst, hunger and diuresis are well marked, in which 
sugar does not disappear on rigid diet, and in which the dis- 
ease runs a rapid course, one to three years, with death from 
coma or phthisis, or in children even in a few weeks, and the 
mild form, in which thirst and diuresis are not well marked 
and in which sugar disappears from the urine on withdrawing 
carbohydrate froms the food. The mild form occurs in old or 
middle-aged and frequently stout persons. 

The writer finds that the mild cases may be clinically 
divided into more manageable and less manageable cases for 
reasons difficult to understand, though in some cases addic- 
tion to sweets undoubtedly explains it. There are a few ap- 
parently mild cases in which thirst and diuresis are not 
marked, but in which it is difficult to remove sugar from the 
urine by strict diet and in which the patient feels worse when 
the sugar is small in amount. 

Intermittent diabetes occurs in which the symptoms disap- 
pear entirely from time to time, but recur after some shock, 
accident or indiscretion, and finally the disease may terminate 
fatally. 



554 DIABETES MELLITUS. 

Diabetes with pigmented skin is known to occur. It is ap- 
parently a pathological and clinical entity. The melanoderma 
is most marked on the face, limbs and genitals, the onset is 
frequently sudden and the course rapid. 

Phosphatic diabetes has been described by Ralfe. It re- 
sembles diabetes insipidus and the urine contains a great 
quantity of lime phosphate. In some instances sugar is 
present and in others it has subsequently appeared. 

Effects and Complications. — The most common are as 
follows : 

Chronic pulmonary tuberculosis, acute pneumonia, asthma, 
gangrene. 

In later stages nephritis with albuminuria, cylindruria, 
and dropsy. 

Cystitis (less common). 

Diabetes and Pregnancy. — According to I^esse : 

i. A womrn suffering from diabetes is liable to serious dan- 
ger if she marries. 

2. The urine of every parturient woman should be examined 
for sugar when possible. 

3. The prognosis of diabetes before the beginning of preg- 
nancy is better than when it develops during pregnancy. 

4. Most of the cases of diabetes developing primarily dur- 
ing pregnancy commence in the last half. 

5. The induction of premature labor is only advisable in 
hydramnion and contracted pelvis. 

6. The urine should be examined for sugar before any 
operation. 

7. Operations on diabetic patients should not be performed 
unless delay in operating means a greater danger to the pa- 
tient than the diabetes. 

Prognosis. — In children the prognosis is bad. The writer, 
out of twenty-six cases coming under his observation, does 
not know positively of a single recovery, though several have 
been lost sight of. Ten are known to have died in periods 



PROGNOSIS IN DIABETES MELLITUS. 555 

varying from a few months to a few years. One is in 
fairly good condition after two years of the disease. 

Seventy-five per cent, of the cases in children observed by 
Stern, 117 in number, died. 

In children, as a rule, the smaller the child the quicker the 
course of the disease, though exceptions occur ; for example, 
a child born with diabetes mellitus has been known to recover 
in eighteen months. 

Out of thirty-four cases in children, reported by Stern, one 
died in two days, and another was alive at the end of five 
years ; seven were cured in less than a year, one recovering in 
a month ; six died in one month ; ten lived more than a year, 
to die finally. 

In fifteen cases in children which the writer has collected, 
in addition to the twenty-six of his own, death. took place in 
all in from six days to eighteen months from the time the 
diagnosis was made, or from the time of coining under obser- 
vation. 

One case, however, a boy of twelve, greatly improved 
under treatment, to be described further on, and is still alive 
(July, 1903) and in fair condition at the end of two years ; but 
sugar in small quantity is still present in his urine. 

In adults the prognosis is better as to time, though the dis- 
ease, when once established (polyuria, glycosuria, loss of flesh, 
etc.), is essentially incurable. The milder cases live for years, 
perhaps as long as twenty years, certainly often ten years or 
more. The severe cases may not live more than a year, the 
usual duration being one to three years in those cases unaf- 
fected by diet or treatment. 

The prognosis is rendered uncertain by the fact that mild 
cases may become suddenly severe, and severe cases improve 
up to a certain point and then linger in statu quo for several 
years. Fat diabetics usually suffer less and live longer than 
lean. 

The writer has seen two cases in young women between 



556 DIABETES MELLITUS. 

twenty and twenty-five. Both died in a year or two from the 
time the disease was sufficiently severe to manifest the usual 
symptoms, although all possible care and the best medical at- 
tention were given them. 

Another young woman of twenty-nine lived to be thirty- 
three. 

In general, the prognosis is ultimately unfavorable, though 
complete recovery doubtless occurs in the milder cases. One 
should always be skeptical about the permanence of an ap- 
parent recovery. Permanent recovery from a severe case 
probably never happens. In mild forms occurring in women 
about the climacteric recovery sometimes takes place. 

The symptoms of diabetes may disappear when it it is asso- 
ciated with pulmonary tuberculosis or nephritis, but death 
will ensue from the complication. 

The writer finds in the case of adults that those who void 
over sixty grammes (930 grains) of urea in twenty-four hours 
seldom live more than a year or two at most. 

Unfavorable Signs. — Sugar is not controlled perceptibly 
by diet and medication ; extreme weakness ; lower extremities 
cedematous ; tongue red, raw and glazed ; mouth and throat 
covered with aphthous patches ; uncontrollable diarrhoea ; 
acute inflammatory affection of the lungs, or, earlier in dis- 
ease, chronic pneumonia. Sudden death from diabetic coma 
possible in such cases, especially when the red reaction with 
ferric chlorid is present in the urine. 

The gradual disappearance of sugar, with the appearance of 
albumin and casts, is always a grave prognostic sign indicat- 
ing chronic nephritis. 

In general the prognosis is unfavorable when the most rigid 
exclusion of the carbohydrates from the diet fails to remove 
sugar from the urine. A practical difficulty in the way of 
utilizing this prognostic indication in private practice is fre- 
quently the addiction of adults to sweets, together with more 
or less self-indulgence and petty deceit, making it impossible 









• UNFAVORABLE SIGNS IN DIABETES MELLITUS. 557 

to be sure in some cases whether a rigid exclusion of carbo- 
hydrates is practiced or not. 

Marked emaciation and loss of strength early in the disease 
is a bad sign. 

Gangrene is an unfavorable indication. 

Family history of severe diabetes is an unfavorable sign of 
importance. 

Cases occurring in poor people are usually severe, and 
neither recognized nor attended to until too late. 

The most unfavorable signs of all, and those indicating 
rapidly approaching death, are the fruity odor of the breath 
and urine, together with the red reaction with ferric chlorid 
in the urine, the presence of grayish granular casts in the sed- 
iment and the onset of drowsiness. 

The presence of signs indicating a pancreatic case is a bad 
one, and the prognosis is then extremely unfavorable. 

Favorable signs are, according to Williamson : 

i. Ready disappearance of sugar by observance of dietary. 

2. Old age. 

3. Obesity, gout or uric acid diathesis. 

4. L/ong duration of the disease without complication or 
much loss of weight or emaciation. 

5. History of a mild form in other members of the family. 

6. Favorable conditions of life. 

7. Climacteric in women. 

8. Transition into insipidus. 

The writer has, however, seen a case in which sugar disap- 
peared from the urine with remarkable rapidity under proper 
dietary, but the patient died comatose in a year's time in spite 
of favorable surroundings. 

On the whole, the most favorable cases are those in which 
the glycosuria is transitory or intermittent, in stout over- 
feeders, or in cases due to mental strain. 

The prognosis in the case of patients under forty is in the 
main unfavorable. 



558 DIABETES MELLITUS. 

Course. — In children the disease runs a rapid course, from 
a few days, weeks or months to one or two years. Occasion- 
ally a child may survive five years. 

In the case of young adults the writer's experience is that 
at most from three to five years is all that can be hoped for, 
and more commonly three, or less, than five. In adults the 
disease may last many years. Many patients live ten years. 

In one of the writer's cases it certainly lasted twenty-three 
years, beginning when the patient was fifty and ending with 
coma at the age of seventy-three. Old people are subject to 
intermittent diabetes; sugar disappears and the patient is 
apparently well. Sooner or later, however, it recurs following 
emotional excitement or grave error in diet. 

Diabetes in neurasthenics is likely to pursue a mild course. 

The form associated with general arterio-sclerosis is usually 
easy to manage so far as the glycosuria is concerned. 

Occasionally diabetes mellitus gradually changes into in- 
sipidus. 

Termination. — In the majority of cases this is due to coma, 
exhaustion or marasmus ; pulmonary consumption carries off 
a number of young persons ; nephritis, furunculosis, car- 
buncles and gangrene are a common cause of death in dia- 
betic cases. 

Cerebral haemorrhage or softening is noticed as a termina- 
tion. 

Quite frequently the termination is by acute pneumonia, 
tubercular broncho-pneumonia or gangrene. 

TREATMENT OF DIABETES MELLITUS. 

When the disease is established, treatment is hygienic, 
dietetic and remedial. The essentials are as follows : 

i. Fresh air with carefully regulated exercise. The im- 
portance of this measure must not be overlooked. 

2. Diet suited to the individual, including use of hot alka- 
line mineral water. 



TKEATMENT OF DIABETES MELLITUS. 559 

3. Regulation of the bowels and functions of the skin. 

4. Internal medication according to symptoms. 

Rest and Exercise. — After every meal rest from half an 
hour to an hour. For exercise, light work in a garden, 
billiard playing, use of light dumb-bells, moderate rowing, 
splitting wood, moderate walking, especially up hill, and 
horseback-riding ; in hot weather driving. All exercise should 
be gentle, and, in the beginning, even cautious. Passive ex- 
ercise may be used at first. 

Carefully regulated mountain-climbing may be beneficial. 
(The writer took a diabetic once on a mountain-climbing 
expedition in the Adirondacks with the utmost benefit ; but 
great care was taken not to allow the patient to become 
exhausted from hunger. It happened on one occasion the 
patient gave up and declared his inability to reach the 
nearest hotel, but after eating a piece of cold beaf-steak felt 
as strong as ever and continued the journey ! ) 

The altitude should not be too high, and on that account 
the Adirondacks are better suited than the Western moun- 
tainous regions. 

Williamson says : 

" The patient should be relieved of mental anxiety and 
worry as much as possible, and the hours of work, business or 
study should be diminished ; a holiday with complete rest from 
work often has an excellent effect on such patients. While in 
the mild form open-air exercise may be of service, in the 
more severe forms vigorous exercise is injurious and the fatigue 
induced by long railway journeys may be dangerous. It is 
well known that marriage has a most injurious effect on dia- 
betic patients." 

The Mental Condition. — The patient should be relieved 
from anxieties and worry so far as possible. Change of scene 
is frequently of much service. Cheerful surroundings, music 
and entertainments are serviceable, but care should be taken 
that the diabetic is neither cooped up in a close atmosphere 
on the one hand nor chilled on the other. 



560 DIABETES MELLITUS. 

Such patients as show a tendency to watch the sugar excre- 
tion closely should be prevented if possible from knowing the 
exact condition, and should be- encouraged in every way. 
But the writer's experience with inveterate cases is that the 
patient somewhat resembles a man who is freezing, i. e., 
is likely to lull himself to indifference from a sense of fancied 
security. The argument made often to the writer is that as 
they suffer no pain and have a " good appetite " there is no 
need of taking dietetic or other precautions. The writer 
thinks that much harm has been done by patting chronic 
cases on the back and assuring them that they are "all right." 
On the contrary, it will be found a difficult task to alarm 
them sufficiently to make them take proper care of them- 
selves. Much judgment must therefore be exercised in influ- 
encing the mental condition of diabetics. The fact that occa- 
sionally a diabetic, who was in no danger at all at the time, 
has been literally " scared to death " is no argument that all 
diabetics should be allowed to think that they are in no dan- 
ger. The average diabetic of y ears* standing will never kill 
himself with worry over his condition. The more the worry, 
the milder the case. But be very careful not to alarm a pa- 
tient who is in early stages of the disease. The writer knows 
of one patient, a physician, who died from the shock of dis- 
covering sugar in his own urine. 

The Sexual Function should be carefully regulated. Mar- 
riage is bad for women and sexual excess for men. 

Warm clothing, warm baths followed by friction, and mass- 
age are useful. 

Massage is particularly useful for patients who are unable 
to take much exercise. Massage should be both general and 
over the abdominal viscera. The regular Swedish gymnas- 
tics are useful also. 

Massage, not too vigorous, may be employed daily between 
breakfast and dinner. Schnee advises a weak solution of 
mercuric chloride in alcohol with a little vaseline to be used 



TREATMENT OF DIABETES MELLITUS. 561 

in rubbing. In some cases, muscular tone is influenced by 
applications of electricity. 

Static electricity is now much in vogue for the treatment 
of diabetes. Waterhouse reports favorable results from use of 
the galvanic current by the production of better nutrition and 
relief of nervous complications, but is not able to say that its 
effect is curative. 

Williamson says electricity is useless in the treatment of 
diabetes mellitus. 

Residence. — Sleeping-rooms should be well-aired and ven- 
tilated. Houses on high grounds to be selected. Hot, stuffy 
rooms to be avoided. Open fire-places a desideratum. Tem- 
perature of dwelling-rooms never below 60 ° nor above 72 ° F. 
Patient should, if possible, sleep in a room adjoining another 
in which the window is open, the door between being open. 
The air in dwelling-rooms should not be too dry in winter. 
Water should be evaporated in the room. In the winter, if 
the patient go abroad, he should seek the Riviera ; in the 
summer, Carlsbad. The sea-shore is better than high alti- 
tudes. In travelling, caution should be taken about fatiguing 
journeys. Frequent stops should be made and rests taken. 

Climatology. — The writer thinks that the benefit obtained 
by diabetics in the Gulf States or California is due more to 
open-air life than to special climatic influences. In general, 
the best climate is where the patient can be out-doors most. 
The mortality from diabetes has been found by Pardy to be 
highest in parts of the United States where there is the low- 
est range of temperature in conjunction with a high altitude. 

Baths. — I have found the Turkish bath useful, especially 
for fat diabetics. Schnee advises first a Turkish bath, followed 
by a short stay in a Russian vapor-bath at a temperature not 
above ioo° F., after which the skin is cooled off by a luke- 
warm shower. The patient is finally allowed to have a sec- 
ondary perspiration on a couch and to rest for upwards of an 
hour. After twelve baths of this kind he claims that the 

36 



562 DIABETES MELLITUS. 

thirst begins to cease. The patient should drink a cup of 
beef tea an hour before entering the bath. At home, sponge 
bathing daily with lukewarm water, quickly followed by rub- 
bing. 

Mineral Springs. — Those most visited are Carlsbad, Vichy, 
Contrexeville, and Neuenahr. The writer thinks that one 
reason why Carlsbad does diabetics so much good is because 
the water there is taken hot. Alkaline waters, however, are 
known to benefit diabetics. 

Management of the Case. — It is the writer's habit when 
consulted by a diabetic to proceed as. follows : 

i. The twenty-four hours' urine is collected and examined, 
not only for albumin and sugar, but for urea, phosphoric acid 
and uric acid. The ferric chlorid test is made. The sedi- 
ment is examined with the microscope. 

2. The patient's weight is noted and the condition of his 
heart and arteries observed. 

3. His clinical history and symptoms are recorded and his 
general condition observed. The condition of the bowels is 
to be ascertained. 

When the ratio of urea to uric acid is low, less than 40 to 1, 
and especially when there is a copious, red, sandy sediment, 
dietetic treatment will improve the condition, but alkaline 
mineral waters as French Vichy should also be administered, 
a glass an hour before each meal. Dietetic treatment, accord- 
ing to Williamson, should be conducted as follows : 

1. In the mildest cases, withdraw all carbohydrates for a 
few weeks, then allow a little bread and, after two weeks 
more, a little more carbohydrate food. 

2. In the less manageable mild cases exclude carbohydrates 
for six or eight weeks, then allow, if possible, a little carbo- 
hydrate food; if not, continue to exclude carbohydrates as long 
as the patient improves, and when he ceases to improve, relax 
the diet to a point where not over 500 or 600 grains of 
sugar daily are passed. 



TREATMENT OF DIABETES MELLITUS. 563 

Use fatty food freely when the patient is put temporarily 
on a rigid diet for diagnostic purposes. 

In stout persons, reduce the total quantity of food, and es- 
pecially of the nitrogenous food, but in emaciated patients do 
not attempt this. 

From the above it can generally be determined whether 
the case is severe or mild. In two cases, however, treatment 
has shown that the division of the disease into these two 
classes cannot be made, since one severe case finally, after 
some months, became mild, and one mild case after, a year, 
became severe without any warning. 

If the case is a mild one, hygienic and dietetic treatment is 
prescribed, as given below, with whatever remedies seem 
suitable. If the ferric chlorid reaction is present, the diet is 
to be less strict and largely to include fats. 

Many writers advise against a sudden change in the diet, 
from the mixed to the strict, but suggest that first one article 
of diet and then another be discontinued. 

In cases where the ratio of urea to phosphoric acid is found 
to be persistently high (above 13 to 1) dietetic treatment alone 
will not suffice. The bowels must be regulated carefully and 
Phosphorus in some form administered. 

In severe cases (those in which the exclusion of carbo- 
hydrates does not result in the disappearance of sugar and 
where emaciation is marked) allow a moderate quantity of 
carbohydrates (potatoes and bread in small quantities) and 
give fatty foods freely; also codliver oil and a little alcohol to 
aid the digestion of the fats. Cream is also allowable and 
possibly a little milk. The latter, however, is only desirable 
when the patient's digestion is feeble. 

A diabetic who is gaining weight, even if there is more or 
less sugar in his urine, is in better condition than one in whose 
urine there is no sugar but who is losing flesh. In the latter 
case the patient may better take one hundred to one hundred 
and fifty grammes (one quarter of a pound) of Graham bread 
daily. 



564 DIABETES MELLITUS 

The Diet in Diabetes. — The writer insists that the matter 
of diet in diabetes mellitus is an important one. 

The proper diet for the patient in question and the proper 
amount of exercise in the open air will accomplish more than 
anything else with which the writer is familiar. 

By all odds the best dietetic method which the writer has 
used is the following. Allow : 

Clam-water. 

Fish, but no oysters and no shell-fish. 

Meat soups, without flour or milk? Beef juice. 

Meats. 

The following vegetables only : 

Lettuce, spinach, cauliflower, cabbage, onions, water cresses, 
asparagus tops, cucumbers. The stalks and white parts of 
lettuce and cabbage are to be avoided. Mushrooms are al- 
lowed. 

The patient is to eat all the lettuce he can in a day, using 
sweet oil as a dressing, liberally if the digestion permits, but 
avoiding the white parts and stalks of the lettuce. 

Eggs and carefully made omelet. Butter, cream, salad oil. 

Cheese. 

Pickles. 

Desserts. Blanc-mange, made of white of egg, beaten up 
and flavored with vanilla, sweetened with a little saccharin; 
gelatin jellies sweetened with a little saccharin. 

Nuts. — Almonds, hazel-nuts, walnuts, Brazil-nuts, cocoa- 
nuts. 

A bill of fare from the above may be arranged as follows : 

Breakfast : Tea or coffee with cream, eggs, ham or cold 
meat. Breakfast should be the lightest meal of the day. At 
eleven o'clock a raw egg with lemon juice, salt and pepper. 

Lunch. — Tea, eggs, cold meat, lettuce and oil, cheese ; beef 
juice if necessary. 

Dinner. — Clam- water, or animal broths without flour, fish 
with butter, hot meat with greens, spinach or cauliflower, let- 



DIET IN DIABETES MELLITUS. 565 

tuce and sweet oil, light claret or Budai wine in small quan- 
tity, almonds. The patient, if used to tobacco, should smoke 
a light cigar immediately after each meal. In the writer's 
experience this is an excellent palliative. 

Drinks. — The patient while on the diet as above is, if con- 
stipated, to drink French Vichy water, one glass one hour be- 
fore each meal, or, in cases in which thirst is a feature or 
which are of long standing, two glasses, hot, half an hour 
apart before meals and bed-time. The influence of hot drinks 
upon the portal circulation is well known. The. power of 
Allouez water, taken hot as above, in quenching the diabetic's 
thirst is remarkable. .. -,„-■ 

Bass' ale contains no glucose, but, according to recent an- 
alysis, a small quantity of maltose (0.86 per cent.) and some 
little dextrine (1.26 per cent.) may be present, so that those 
who drink it should observe the action, if any, on the urine. 
. . Other drinks are a little brandy, cognac or old whiskey, 
Hungarian, Carlowitz or Budai wine; lemonade from fresh 
lemons, sweetened with saccharin; water containing dilute 
acids. 

Regulation of the Diet. — No bread at all is at first allowed. 
At the end of three or four days or a week it will be found 
that the sugar in the urine, has decreased materially, after 
which a maximum of four ounces of white bread daily may 
be allowed. Later a baked potato at dinner and an apple 
daily. Even in cases where the patient insists on gluten 
bread or cakes made from diabetic flour, this diet is effective, 
provided at the same time exercise in the open air is methodi- 
cally taken. 

For the first two days this diet is arduous, but trie patient 
soon begins to feel so much better that the advantage of it is 
appreciated. In rare cases — once only in the writer's experi- 
ence — although sugar is very materially reduced in amount 
in the urine, the patient feels weaker than before. In the one 
case in which this occurred the patient was closely confined 



566 DIABETES MELLITUS. 

in an office, could not or did not take out-of-door exercise 
methodically and, moreover, showed in his urine an abnor- 
mally high ratio of urea to phosphoric acid, always above 15 
to 1. Daily regulation of the bowels and administration of 
hypophosphites (without sugar) soon overcame the weakness, 
and the patient can now eat more freely without increasing 
the sugar. 

The diet above described must not be continued too long. 
As already specified, at the end of a week bread, in small 
quantity, a baked potato, an apple of, in some cases, a peach 
may be added. The urine must be tested to see whether 
these articles increase the amount of sugar ; if not, the patient 
can then, as a rule, be put on the following diet : 

Shell-fish and Fish. — Oysters cooked in any way without 
milk or flour. Clam-water. All kinds of fish, but sauces 
should contain no flour. Soft-shell crabs and fish-roe for those 
with whom they agree ; the same may be said of fish-balls 
(made without potatoes or flour), shrimps, craw-fish, caviare, 
sardines. 

Soups. — Consomme (beef, veal, chicken or turtle), with 
asparagus points, okra, ox-tail, turtle, terrapin, oyster or clam, 
but all without flour or milk ; mock turtle soup, mullaga- 
tawny, tomato, gumbo fillet. Beef tea. 

Meats. — Beefsteak (with or without fried onions, according 
to digestion), broiled chicken, lamb chops, tender mutton 
chops, roast beef, roast mutton, game (for those with whom it 
agrees). Tongue, sweetbreads, lamb fries. Poultry should 
not contain dressing made of bread or flour ; currie should not 
be thickened with flour. (No liver allowed.) Meat broths, 
extracts, somatose. 

Vegetables. — Lettuce, spinach, cauliflower, cabbage, toma- 
toes, radishes, oyster-plant, celery, onions, string beans, water 
cresses, sorrel, mushrooms, asparagus tops, endives. (Those in 
italics should not be given to patients whose digestion is 
weak.) 



DIET IN DIABETES MELLITUS. 567 

Relishes. — Pickles, sardines, anchovies, olives. (Not to 
every patient, but according as they agree.) 

Eggs. — Poached, scrambled with a little chipped beef, soft 
boiled ; carefully made omelet or ham omelet in small quan- 
tity, eaten when warm. (In some cases omelets do not agree.) 

Substitutes for Sweets. — Brandy peaches, without sugar ; 
wine jelly, without sugar ; kirsch and rum jellies, without 
sugar ; glycerin, saccharin. If saccharin is used with tea or 
coffee, add it before cream. A single grain suffices for a cup 
of coffee. Too much saccharin should be avoided. Many 
do not like it, and in some it causes serious gastric troubles. 

Miscellaneous. — Butter ; cheese, if not too constipating ; 
salads and salad oils, except potato salad ; lean patients, whose 
digestion is good, may take considerable fat. Sauces to be 
made without flour or sugar ; if to be thickened, use gluten 
flour. Cream is allowable. 

Desserts. — Blanc-mange, made of white of eggs, beaten up 
and flavored with vanilla, sweetened with a little saccharin. 
One apple, not sweet. A few almonds, hazel-nuts, walnuts. 
Cheese, cranberries, strawberries, plums, cherries, lemons ; if 
stewed, add a little sodium bicarbonate. 

Bread. — Gluten bread, sparingly used. In cases where the 
patient is grievously disappointed in giving up bread, allow 
him ordinary bread in small quantity, as a psychical measure. 
But if the loss in sugar overbalances the psychical gain, be 
sure to cut off the ordinary bread at once. The various 
gluten and diabetic flours usually contain more or less starch 
and should be sparingly used, but can be allowed in greater 
quantity than ordinary flour. If the patient does not like the 
gluten flour, he may usually be allowed two to four ounces of 
wheat bread daily. 

He may also try peanut flour, which is best utilized in the 
form of German pancakes. It is sold by Burnett & Co., India 
Street, Boston. (See also Dietetic Specialties.) 

Diabetic baking-powder biscuit may be made by mixing 



568 DIABETES MELLITUS. 

gluten flour and diabetic flour in equal proportions, with ad- 
dition of an egg and not too much baking-powder. To be 
eaten cold. 

If the patient eats bread the best forms are rusk, rye-bread 
and the crust of French rolls. 

The dietetic treatment alone, according to Stern, suffices 
for all patients exhibiting the usual symptoms of diabetes 
mellitus, whose urine is free from acetone, diacetic and beta- 
oxybutyric acids, until all symptoms have completely sub- 
sided, or until all symptoms except glycosuria, which mean- 
time has declined to less than one per cent., has disappeared. 

Analysis of American Food Products. — The following 
table shows the percentage of carbohydrates in various arti- 
cles of food : 

Per cent. 

Salt mackerel, canned in oil, . i.i 

Clams, long, in shell, i.i 

Clams, round from shell, . . 5.2 

Lobsters, whole, 0.2 

Oysters in the shell, 0.7 

Scallops as purchased, 3.4 

Shrimps as purchased, . . 0.2 

Whole milk, 5.0 

Skim milk, 51 

Buttermilk, 4.8 

Cream, 4.5 

Brie cheese, 1.4 

Pineapple cheese, 2.6 

Roquefort cheese, .... T.8 

Whole milk cheese, 2.3 

Skim milk cheese, . . .2.2 

American pale cheese, none 

American red cheese none 

Meals (various), 75 to 79. 

Macaroni, etc., 73. 

Asparagus, 0.7 

Beans (string), ..... 9.4 

Beans (dried), 59 to 67. 

Beets, 7.7 

Brussels sprouts, 3.7 

Cabbage, 4-9 



DIET IN DIABETES MELLITUS. 



569 



Per cent. 



Carrots, . . 
Cauliflower, 
Celery, 
Corn (green), 
Cucumbers, 
Eggplant, . 
Greens, . . 
Leeks, . . . 
Lentils, . . 



7-4 
6.0 

30 

14.1 
2.1 

5-i 

8.9 

5-o 

58.6 



Lettuce, . 
Onions, 
Parsnips, . 
Peas, green, 
Peas, dried, 
Peas, sugar, green 
Potatoes, boiled, 
Potatoes, sweet, 
Spinach, . . . 
Tomatoes, . . 
Turnips, . . . 
Apples, 

Bananas, yellow 
Blackberries, . 
Figs, fresh, . . 
Grapes, . . . 



Per cent. 
27 
8.9 
I2.9 

80 

61.5 

8.0 

22.3 

23.I 

3-i 

3-9 

6.1 

12.4 

13-7 

7-5 

18.8 

13-3 



Oranges, - 7.1 

Pears, 10.6 

Pineapples, 9.7 

Pineapples canned, ... 36.4 

Prunes, fresh, 17.4 

Raspberries, ........ 12.6 

Strawberries, 6.1 

Dried fruits (such as apricots, 
dates, figs, prunes, raisins, 

59 to 75. 



Cocoanuts, 
Peanuts, . 
Chocolate, 
Cocoa, . . 

Almonds, 
Mushrooms, 



3i-5 
16.3 
26.8 
37.7 
3-o 
1-7 



From these tables it will be seen that articles containing 
five per cent, or less of carbohydrates are salt mackerel, 
canned in oil; long clams in shell, lobsters, oysters, scallops, 
shrimps, whole milk, skim-milk, buttermilk, cream, cheeses? 
asparagus, sprouts, cabbage, celery, cucumbers, leeks, lettuce, 
spinach and tomatoes. Of these those containing three per 
cent, or less are salt mackerel, canned in oil; long clams, 
lobsters, oysters, scallops, cream, cheeses, asparagus, celery, 
cucumbers, lettuce and spinach ; the last a little over three 
per cent. 

The Use of Substitutes for Sweets. — The patient should 
be urged to give up the use of glycerin or saccharin as a 
sweetener. 



570 DIABETES MELLITUS. 

In the writer's opinion diabetics are addicted to the use of 
sweets and cannot be depended upon to avoid them as long as 
they use any at all. 

The writer is rather skeptical about the observance of diet 
by diabetics. A diabetic will diet scrupulously for a few days, 
especially when he is alarmed, but is likely, except early in 
the disease, when the will-power is unimpaired, to indulge 
himself in forbidden articles, so that in the long run the diet 
is at best only relatively adhered to. 

Patients who have had diabetes for years seldom pay much 
attention to diet. The disease slowly progresses, the sub- 
stances causing the ferric chlorid reaction appear in the 
urine and then the diet is powerless to save them. 

It will be noticed that in neither of the above diet lists is 
milk allowed. The writer's experience with milk is that it 
increases the sugar and the amount of urine voided. 

Resume of Dietetic and General Treatment. — The points 
insisted on by the writer may be summarized as follows : 

i. There are two classes of diabetic cases considered with 
reference to the ferric chlorid reaction ; unmanageable cases 
and more or less manageable ones. 

2. Patients easily alarmed are more manageable than those 
who are not. 

3. In the treatment of diabetes mellitus regard must be had 
for the addiction to sweets. All persons fond of sweets are 
not diabetics, but nearly all diabetics are fond of sweets. 

4. Fondness for sweets leads to ingestion of articles con- 
taining glucose itself. 

5. The diabetic diet should be supplanted after a short time 
by diet for the diabetic in question. 

6. After sugar is reduced to one per cent, the diabetic 
should be allowed to eat anything which fails to increase the 
amount of sugar in the urine, always excepting all sweet 
things. Even if the patient can eat cane-sugar he should not 
be allowed to do so for reason explained in 4 above. 



DIET IN DIABETES MELLITUS. 571 

7. Glycerin and saccharin should be prohibited for the 
same reason. 

8. Certain green vegetables, as spinach, lettuce, etc., should 
be insisted on, not merely recommended. 

9. Hot alkaline mineral water, especially if laxative, is un- 
doubtedly of value taken before meals. 

10. Moderate exercise in the open air should be insisted 
on. Trips to Carlsbad, without stay in Paris or London, are 
to be recommended, whenever convenient, in mild cases, but 
not in the severe ones. 

Ill Effects of Diet. — In some of the more severe cases of 
Class 2a the patient may be found to lose weight rapidly on 
a rigid dietary. In such cases Williamson finds that the diet 
must be relaxed so that the patient voids about five hundred 
grains of sugar daily. If the diet does not decrease the 
amount of sugar and at the same time the patient loses weight 
or is generally worse, then there must be allowed bread and 
milk, fatty food, and especially cream and butter. 

If the patient steadily loses ground under dietetic treatment 
or if long-continued dietetic treatment cannot effectually bring 
about cessation of the symptoms, then the diet must be aban- 
doned and reliance placed on drugs alone. The same may be 
said when the amount of sugar is less than one per cent, and 
some other disorder is present, or in which continued mental 
excitement brings about a recurrence. 

In cases where the patient for any reason cannot observe 
dietetic and hygienic measures drugs must be given in addi- 
tion to whatever other measures he can execute. 

Dietetic Specialties. — Hard-boiled eggs with plenty of but- 
ter, omelette. Custard made of eggs and milk, or better as 
follows : One egg beaten up well, to which is gradually added 
a mixture of cream and water boiled, the mixture being 
stirred when added. Place in a pan over the fire and keep 
stirring until thick, then pour into a glass. Do not let the 
mixture boil. Flavor with cinnamon and sweeten with sac- 
charin if desired. 



572 , DIABETES MELLITUS. 

Dr. Williamson has prepared an artificial milk, practically 
free from sugar, which he says may be taken in unlimited 
quantities by diabetic patients in all forms of the disease. 
Four tablespoonfuls of cream are added to a pint of water and 
well mixed ; the mixture is allowed to. stand in a cool place 
and at the end of twelve hours the fat of the cream will have 
floated to the surface and can be skimmed off ; to this are now 
added water, the white of an egg and a little salt, and, if de- 
sired, a trace of saccharin. . By practice an artificial milk can 
thus be prepared modified to suit the patient's taste. 

Cream itself may be taken to the amount of nearly a pint 
daily, in small quantities at a time. An emulsion of peach- 
kernel oil free from prussic acid may be made by mixing the 
oil, fifty per cent, by volume, with yolks of eggs, elixir of sac- 
charin, spirit of chloroform, the yolk of egg, and almond and 
cinnamon essences. It is much, more palatable than cod-liver 
oil. A very useful fat emulsion is that ol Russell. 

Mannite or manna sugar may be given with coffee in 
amount not to exceed thirty grains daily. 

Saccharin and saxin can be used as sweeteners for various 
articles of diet. . 

Peaches, apricots and melons are .the least objectionable 
fruits ; also stewed green gooseberries. 

Nuts, except chestnuts, are allowable. 

If potatoes are greatly craved they may be allowed in small 
quantities cooked as potato chips. A potato " cure " has 
recently been advised. 

Substitutes for bread are the following : 

Torrefied bread, made by toasting thin slices until they are 
almost black. 

Gluten bread, which does not give a deep blue black color 
with a drop of Lugol's solution (iodine in solution of potas- 
sium iodide). 

Gluten bread is made by mixing one pound of flour with 
about a pint of water, placed, immediately after mixing, in an 



DIETETIC SPECIALTIES IN DIABETES MELLITUS. 573 

oven heated to 430 ° F. Loaves should be baked an hour and 
a half and rolls three-quarters of an hour. Flavor with a 
little salt before baking. 

Gluten pudding may be made by baking a batter of eggs, 
cream and gluten flour. Gluten pancakes are made by add- 
ing the flour to one or two eggs and beating into a batter ; 
sweeten with saccharin or glycerin. 

Almond cakes can be made by mixing one pound of ground 
almonds, four eggs, two tablespoonfuls of milk and a pinch 
of salt. Beat up the eggs first, then stir in the flour. Bake 
for about fifteen minutes at a moderate heat. A pudding can 
be made by using two eggs, one quarter-pound almond flour 
and one quarter-pound butter. 

Ebstein's aleuronat bread contains considerable starch ; 
Williamson, therefore, prefers cakes and buns made out of 
cocoanut and aleuronat, which he highly recommends. The 
sugar must be removed from the desiccated cocoanut powder 
by fermentation. Two ounces of aleuronat, two of cocoanut, 
one beaten-up egg and a little water sweetened with saccharin 
make the cakes. To make the buns proceed as follows : 

Two ounces of desiccated cocoanut powder are mixed with 
a little yeast and water and kept in a warm place (by the fire) 
for fifteen to twenty minutes. Then two ounces of aleuronat 
are mixed well with one teaspoonful of baking powder and a 
little salt. After the action of the yeast the cocoanut powder 
is added to the aleuronat, together with one egg beaten up, 
and water (sweetened with saccharin or saxin, if preferred). 
The mixture is worked into a thin batter, and this is then 
placed in deep tins or tart dishes, which are put at once into 
a hot oven for twenty to thirty minutes. When half baked 
the buns or rolls may be glazed with a little egg-albumin and 
then placed in the oven again until browned. The above 
directions indicate the proportions of the substances, but, of 
course, large quantities can be employed. 

Aleuronat Pancake. — Take one egg ) beat up in a little 



574 DIABETES MELLITUS. 

water and cream ; take two tablespoonfuls of aleuronat pow- 
der ; add half a teaspoonful of baking powder and a pinch of 
salt ; mix well, then add gradually to the egg and cream, and 
beat into a batter ; allow to stand five minutes. If too thick, 
add a little more cream and water. 

Fry as an ordinary pancake, in a frying-pan with a little 
lard. At the end of about eight minutes, when the under 
surface is browned, turn it over and continue to heat for 
about five minutes longer. 

Aleuronat and Suet Pudding. — Take two ounces aleuronat 
flour, two ounces suet, one egg } a pinch of salt, half a tea- 
spoonful of baking powder. Sprinkle a little aleuronat flour 
on a chopping-board. Chop the suet on this part of the 
board. Then mix all the aleuronat with the chopped suet in 
a basin. Add the salt and baking powder. Beat up the egg 
in about three tablespoonfuls of water, to which a little sac- 
charin has been added. Then add the egg gradually to the 
mixed aleuronat and suet, stirring the whole mass well into 
a paste. The addition of a little more water may be neces- 
sary. Drop into a tin pudding mould, smeared with butter or 
lard, and float it in a pan of water, and boil for two hours, 
taking care that the water does not flow over into the pudding 
mould ; or, better still, the pudding may be baked in the oven. 
The addition of almonds (half-ounce) improves the taste. It 
can be eaten with a little red wine as a sauce. 

Use six or seven ounces of ordinary white flour, the same 
of aleuronat, five ounces of the best butter, one teaspoonful of 
salt, three-quarters of an ounce of baking powder. Mix the 
flours in a warm dish, gradually add the melted butter and 
lukewarm milk, then the salt, and finally the baking powder. 
Mix well and bake at a good heat. 

Mixed fats (Russell emulsion) is flavored with cloves, which 
to a few patients is unpleasant. It should be taken in plenty 
of very hot water. 

Suet may be freely used in various articles of diet. 



DIETETIC SPECIALTIES IN DIABETES MELLITUS. 575 

A little alcohol remedies the tendency to indigestion when 
fats are taken. 

In cases of fatty stools, fats can not be digested in large 
quantities. 

Diarrhoea due to diet rich in fat should be treated with Bis- 
muth, Calcium carbonate and Opium if necessary. 

Cocoanut dishes are as follows : 

Three tablespoonfuls of cocoanut powder are mixed into a 
paste, with a little German yeast and water. The mixture is 
allowed to remain by the fire, or in a warm place, for about 
twenty minutes, until fermentation occurs, and it becomes 
"puffy." Then a little of a watery solution of saccharin is 
added. 

One egg is beaten up, and this, with two tablespoonfuls of 
cream and a little water, are added to the cocoanut paste. 
The whole is well mixed and dropped into small tins, and 
baked in an oven for about thirty minutes. 

These cakes are excellent, but contain so much fatty mate- 
rial that in many persons they cause slight dyspepsia. This 
may easily be prevented by taking a little wine, or alcohol in 
some form, soon after eating the cakes. (Williamson.) 

Saundby gives the following directions for the preparation 
of cocoanut and almond cakes : 

Three-quarters of a pound of the finest desiccated cocoanut 
powder, one-quarter pound of ground almonds, six eggs, half 
a teacupful of milk. Beat up the eggs, and stir in the cocoa- 
nut and almond flour. Divide into sixteen flat tins, and bake 
twenty-five minutes in a moderate oven. 

Aleuronat now used in the preparation of diabetic foods is 
wheat albumin. 

Ebstein has recently recommended another vegetable albu- 
min, ergon from rice, and Pickardt roberat from corn. 

Treatment of Prodromal Stage of Diabetes. 

In the prodromal stage of Stern his treatment is merely to 
diminish the food-supply, prohibiting only alcoholic drinks 



576 DIABETES MELLITUS. 

and especially malted beverages, but insisting on regularity 
of meals. He commends milk and American' cheese, par- 
ticularly the latter. The writer has found in several instances 
that a rigid diabetic diet for -thirty days will cause dis- 1 
appearance of sugar, loss of flesh, and improvement in the 
general condition of the patient. At the end of that time 
the usual diet may be resumed, but the amount of food must 
be barely enough to satisfy the craving and sustain the 
strength. 

Stern believes in a radical change of climate for the person 
in the preglycosuric stage. The changed external conditions 
bring about a regeneration, and if an eventual deterioration 
has not progressed beyond a certain point, the regained vital 
energy will in many instances do away with functional dis- 
turbances and ward off or even prevent molecular death. 

Stern advises air-baths. The patient sits, undressed, in a 
room (which is warm enough to prevent a feeling of chilli- 
ness, but not purposely heated), or, better, perforins gym- 
nastics. 

The remedies which the writer uses in the prodromic stage 
are chiefly digestive powders, Carlsbad sprudel salts, and 
hepatic stimulants. If necessary Arsenicum, Uranium nitrate, 
or Aurum. 

Sodium glycocholate. — The indications for the use of this 
substance are hepatic insufficiency, as evidenced by the dirty 
brownish discoloration of the skin, often associated with a 
slight yellowness of the eyeball, while on urinary analysis 
traces and sometimes more than traces of bile pigment can 
be detected, pointing to a deficient elimination of bile pig- 
ment by the liver, the presence of an excess of urinary pig- 
ments, urosein, ethereal sulphates, indol and increased pro- 
portion of neutral sulphur as well as clinical symptoms 
pointing to an hepatic insufficiency. The dose is 5 to 15 
grains three times daily. 



TREATMENT OF DIABETES MELLITUS. 577 



MEDICAL TREATMENT OF DIABETES MELLITUS. 

Symptomatic Treatment. — The following remedies are 
often indicated : 

Arsenicum. — In the writer's experience this is the principal 
remedy and is best given in the second decimal. The indi- 
cations are insatiable hunger and unquenchable thirst, 
emaciation, loss of strength, pallor, disposition to gangrene, 
dryness of the mouth and throat, great polyuria, watery diar- 
rhoea, slight motion causes dyspnoea with palpitation and 
fainting. Cowperthwaite uses the Iodide of Arsenic in the 
third decimal. 

Creosote. — Heaviness, drowsiness, depression of spirits, 
head confused and dull ; very severe chronic neuralgic 
troubles. Use first decimal or drop doses of the crude drug. 

Phosphoric acid. — Of value when the case is evidently of 
nervous origin ; when there is loss of fluids, particularly 
seminal ; patient is indifferent to all things ; long-lasting 
diarrhoea. Use the first decimal. 

Uranium nitrate. — Languor, marked and general. Ex- 
cessive thirst. In cases originating in dyspepsia or digestive 
derangement. To be given in the lower potencies, or one- 
grain doses of the crude drug. 

Bryonia. — Dryness of the lips and tongue, persistent 
marked bitter taste in the mouth, invariably aggravated 
shortly after eating, or even drinking. Quantity of urine 
not so great, but specific gravity high. Pruritus vulvae. 
Sleep disturbed and unrestful. Often loss of appetite and 
marked debility. 

Lactic acid. — Immense quantities of urine, inordinate thirst 
and hunger, gastric symptoms marked (acidity, sour burning 
risings), marked intermittent protrusion of the eyeball and 
great dilatation of the pupil. 

Morning urine contains but little sugar; afternoon and 
evening much. 
37 



578 DIABETES MELLITUS. 

Lithia. — For the pains in the head, chest, back and joints 
the writer uses ordinary Lithia tablets, five grains in water, 
twice to four times daily, or Lithium benzoate in 2- to 10-grain 
doses. 

Chionanthus is indicated when there are the following 
symptoms: Intense thirst, specific gravity of the urine, 1030 
to 1040, frequent and copious urination, more or less nervous 
prostration, loss of weight, night sweats and, in a large per- 
centage of cases, constipation and stool void of bile, being 
white in color. 

Waterhouse says : 

" Where there is no febrile condition and nervous depres- 
sion Lloyd's specific Nux vomica should be combined with 
Chionanthus. I prescribe Chionanthus in from ten to fifteen 
drop doses, and the Nux in from one-half to one drop doses, 
when combined, four times daily. The bowels should be 
flushed every morning, one hour before breakfast, by drink- 
ing one to two pints of hot water, to which should be added 
one-half to one teaspoonful of Sulphate of Magnesia, or, 
what is preferable, one-half to one wineglass of French Lick 
Pluto water in one pint of hot water. This line of treatment 
should be continued until the specific gravity of the urine is 
normal." 

In addition to the' above, Argentum nitricum (Cowperth- 
waite uses the thirtieth), Asclepias vincet. in gouty cases ; 
Lactuca, Helonias, Natrum sulphuricum, Kali carbonicum, 
Nux vomica, Plumbum (when complicated with nephritis), 
Leptandra, and many other remedies have been used or sug- 
gested. 

The writer uses Arsenicum, Phosphoric acid and Uranium 
nitrate, but is unable to attribute favorable results entirely to 
these remedies, as dietetic and other measures, without any 
remedies at all, have done just as well. 

Palliative Treatment. — Williamson concludes that the 
drugs which appear to be most deserving, if tried, are Opium, 



PALLIATIVE TREATMENT OF DIABETES MELLITUS. 579 

Codeine, Morphine, Arsenic, Antipyrin, Sodium or Bismuth 
salicylate, Jambul, Uranium nitrate, Cod-liver oil ; to which 
add brewer's yeast, or Cerevisine, the Lecithins, Aspirin, and 
Hydrastis. 

Opium. — Diabetics sometimes tolerate this drug remarkably 
well. It is useful in controlling thirst, and is indicated for 
restlessness and sleeplessness. Codeine, with rigid diet, may 
be given in one-half grain doses three times daily, and usually 
can be rapidly increased in amount until fifteen or even thirty 
or forty grains per diem are taken ; it should then be gradu- 
ally withdrawn. In some cases Codeine fails to relieve the 
symptoms described above. The Extract of Opiitm may then 
be tried, beginning in one-quarter grain doses, three times 
daily, and slowly increased to four or eight grains in the 
twenty-four hours ; some patients may tolerate even ten 
grains per diem. 

Laudanum in doses of from sixty to one hundred drops a 
day in three doses, is said, by Striimpejl, to give good results 
without apparently affecting the bowels. 

Opium is bad when it causes constipation, when coma 
threatens and when there is nephritis. 

Williamson states that he has had better results with 
Opium or Codeine than with any other drug. 

Morphine, if given, should be by the mouth, in doses of 
one-sixth of a grain three times a day, until the patient is 
able to take one grain three times daily without ill effect, un- 
til fifteen or twenty grains are given three times daily, discon- 
tinuing every three or four weeks for a few days, and resuming 
again. West reports in all eight cases helped by it. 

Quinine may help malarial cases. 

Mercuric chlorid is highly recommended by Dr. I. N. 
Danforth, of Chicago. He gives it in doses of from one-tenth 
to one-fourth of a grain. 

Arsenic. — As a routine practice Arsenicum, either alone or 
in combination, is perhaps the most frequent prescription 



580 DIABETES MELEITUS. 

given to diabetics. Combined with bromine in the form of 
Clemens* Solution it is given in five-minim doses, or more 
after tolerance. 

The Arsenite of Bromine in one-sixteenth of a grain, in- 
creased to one-sixth, may be used instead. The Arsenite of 
Iron in pill form, in doses of one-sixteenth of a grain, is rec- 
ommended in cases complicated by anaemia or malaria. The 
dose may be gradually increased to one-eighth or one-sixth 
grain. 

Fowler's Solution, in drop doses or more, is sometimes 
given. 

The Bromides of Arsenic and Gold, in the preparation 
known as Arsenauro, are credited with cures. 

The writer as yet, however, has been able to manage his 
cases by means of diet, exercise and hot alkaline waters, with- 
out the use of crude drugs except as a last resort. 

Extensive trial of Arsenical preparations by various phy- 
sicians has resulted in skepticism as to their value. 

Antipyrin may be useful for the pains in the limbs, but 
otherwise is of doubtful value and may do harm to the diges- 
tion and kidneys if given too long. The dose is from 30 to 
60 grains daily. The writer has not as yet used it. 

Osier advises it in neurotic cases in doses of ten grains 
three times daily. 

Jambul. — This agent appears to have the power to diminish 
the secretion of urine. The fluid extract of Java jambul 
should be used, given in capsules of ten minims each, one 
capsule three times daily, increased to four or five capsules at 
a dose. The seed of jambul should not be heated in the 
manufacture of the fluid extract. 

The writer has seen several cases in which this drug acted 
favorably so far as controlling the secretion of urine is con- 
cerned. 

Sodium salicylate may be of service in gouty cases. The 
dose is from ten to twenty grains daily. Aspirin may be 
preferable. 



PALLIATIVE TREATMENT OF DIABETES MELLITUS. 581 

Sodium bromide may be given in doses of fifteen to twenty 
grains, well diluted, in cases where there is great nervous ir- 
ritability or excitement. 

Uranium nitrate may be of considerable value. The dose 
is from one to two grains, well diluted, twice a day, after 
meals, increased every few days. 

Oxygen. — Inhalations of from three to five gallons daily 
may be used, diluted with an equal volume of atmospheric 
air and inhaled slowly and deeply, half a minute or so of rest 
being allowed between each inhalation. 

Benzosol as an intestinal antiseptic, together with Carbon- 
ate of Lithia and Fowler's solution, is said to help some cases 
of diabetes. 

Acetozone may become useful like the above. 

Other remedies sometimes indicated are : Nitric acid, in 
early stages, when there are crops of boils ; Graphites, L,ep- 
tandra, Podophyllum, Aurum muriaticum, Mate. 

Anti-syphilitic treatment by Mercurial inunction and ten 
grain doses of Iodide of Potassium may be of service when a 
history of syphilis preceding diabetes is to be had. But mer- 
curial stomatitis and dysentery may be caused by the mer- 
curial treatment or other and fatal complications, as gangrene 
or pulmonary tuberculosis. 

Lactic acid and Methylene blue have been used with claimed 
success. 

Cod-liver oil should be used, as well as Lipanin, peach- 
kernel oil, Petroleum emulsion and Russell's emulsion in 
emaciated cases. 

The frothy part of fresh yeast has sometimes produced 
good results. Brewer's yeast is also worth trying, or Cerevi- 
sine. 

Pancreatic extract is probably of no value. Pancreas graft- 
ing may possibly be of service. 

Raw calf pancreas helped one of Dr. R. H. Fitz's cases. 

The rectal injection of extract of liver and thyroid extract, 
internally, in small doses, has also been tried in this country. 



582 DIABETES MELLITUS. 

Special Therapeutics. — In the writer's experience drugs 
have but little or no curative action when the disease is once 
chronic. Palliative treatment for the various symptoms which 
give most distress is to be pursued as follows : 

For the Pains. — Those which are usually in the head, 
chest, back and joints the writer finds relieved by the salts of 
Lithium, as Lithium benzoate in 2- to 10-grain doses. For 
lancinating pains Codein is palliative in ^-grain doses. Anti- 
pyrin, 10 grains in an ounce of peppermint water, three times 
daily, for gnawing pains in the legs is recommended. 

For the Constipation. — A teaspoonful of Carlsbad Sprudel 
salt in a glass of hot water an hour before breakfast. In 
some cases the faeces may have to be removed by more vigor- 
ous measures, so dry does the mucous membrane become. 
In mild cases Kutnow's powder acts well and is pleasant to 
take. 

In one or two severe cases of constipation Rubinat water 
was found efficacious by the writer. It may be necessary at 
times to give Mercurius dulcis, followed the next morning by 
aperient water. 

For the Depression of Spirits. — The chief remedies are 
Arsenic and Aurum, particularly the latter, in the lower 
potencies. 

For the Insomnia and Debility. — The writer uses Phospho- 
glycerate of Lime in doses one capsule (4 grains) (not the 
wine nor the syrup) three times daily. Sometimes, also, the 
hypophosphites without sugar, or a phosphorus and calisaya 
mixture without sugar. The various Lecithins may be tried. 

Two teaspoonfuls of good beef-juice in water are service- 
able when the patient wakes up hungry at night or " gives 
out " in the afternoon before dinner. Unfortunately the 
salty taste prevents many patients from taking this nourish- 
ing article. Somatose may, therefore, be serviceable in such 
cases. 

Diarrhoea. — When attacks of diarrhoea come on the pa- 



SPECIAL THERAPEUTICS OF DIABETES MELLITUS. 583 

tient may subsist on beef-juice and barley-water for the time, 
and take Salicylate of Bismuth, eight grains twice daily. 

In diabetic steatorrhcea Wegele advises use of Pankreon. 

For the Thirst. — Hot alkaline mineral waters, two glasses, 
half an hour apart, before each meal and before going to bed. 
In gouty cases this treatment sometimes reduces the sugar 
to a trace or causes it to disappear altogether. 

The writer uses Allouez water, as stated above. Chewing 
roasted coffee sometimes relieves thirst. Water acidulated 
with lemon juice or acids may be used. 

Accidents. — In cases of accidents involving concussion of 
the brain and followed for considerable time by notable slow- 
ness of the pulse, all mental excitement and exposure to ex- 
cessive heat of the sun should be avoided for a year. 

Mouth-Wash. — For the disinfection of the mouth a solu- 
tion of Chlorate of Potassium, i in 19, is made, and a tea- 
spoonful of this added to a pint of water to which a little 
alcoholic solution of thymol is added. The mouth is well- 
rinsed with this mixture several times daily. 

A weak solution of Boric acid or of Borax in camphor- 
water may be used, or Borax, two drachms ; Boric acid, one 
drachm ; Potassium chlorate, one drachm, mixed and dissolved 
in twenty fluidounces of camphor-water. A three per cent, 
solution of Bicarbonate of Sodium is used for a mouth-wash ; 
also a solution of Aluminium acetate, one part, in water two 
hundred parts, after each meal. 

Gastric Disturbances. — The writer has used Taka-diastase 
and Caroid. Waterhouse advises Lloyd's Asepsin in solution, 
four grains to the ounce, together with Subnitrate of Bismuth. 
Pancreatic extract after each meal may be useful. William- 
son has found ten grains of Bicarbonate of Sodium in a tea- 
spoonful of milk of service for the dyspepsia. 

Roberts, for the craving for food and sinking at the epigas- 
trium, gives two or three grains of Asafcetida in a pill, two or 
three times a day. 



584 DIABETES MELLITUS. 

Itching of the skin requires warm baths, frequent sponging 
and regulation of the bowels. Savill's prescription is as fol- 
lows : 

#. Calcii chloridi, 20 to 40 grs. 

Tincture Aurantii, . . 5^- 

Aquae chloroformi, S^> ^ d.s 

Pruritus and eczema of the vulva are troublesome condi- 
tions. After urinating, the patient should dry the meatus 
with absorbent cotton, and apply chiolin twice daily, or a lo- 
tion of Boric acid, or of Sodium hyposulphite, one ounce in 
one quart of water : or Ichthyol and lanolin ointment ; or an 
ointment composed of ten grains of Potassa sulphurata, to one 
ounce of benzoated lard ; retain by use of napkin or absorbent 
cotton. 

The parts should first be bathed in warm water, using 
chiolin soap, then rinsed with clear water, dried gently by 
pressing with soft, clean towels heated in an oven, after which 
the chiolin may be applied. 

W. S. White, of Chicago, in cases of eczema, advises bath- 
ing with milk instead of water. 

Corns. — Williamson points out the danger of cutting corns 
in diabetic cases, for fear of troublesome trophic ulcers, per- 
forating ulcers, or superficial gangrene. 

Sleeplessness may require Chloralamide, Sulphonal, Opium, 
or the Bromides, if there is also much nervous excitement. 

Cutaneous oedema, not due to nephritis, requires rest in bed 
and Iron internally. 

Gangrene. — Fulton reports practical disappearance of sugar 
from the urine in a case subsequently operated on for gan- 
grene, by use of a tablet composed of Antipyrin, two grains ; 
fluid extract Jambul seed, two minims ; Codeine sulphate, one- 
half grain. Before amputation of the member the patient 
took these tablets for some time. The operation was success- 
ful and the wound healed kindly. 

For local treatment of gangrene the parts are to be dressed 



SPECIAL THERAPEUTICS OF DIABETES MELLITUS. 585 

with iodoform and cotton, and access of air allowed. If there 
is cellulitis, free incisions should be made. Amputation 
will be necessary when (i) the fever persists and cellulitis in- 
creases, and (2) the glycosuria persists in spite of anti-diabetic 
treatment. 

In cases of gangrene with extensive atheroma, according to 
Godlee, amputation should not be lower than the knee. 
When due to neuritis, amputation is not advisable, or, if per- 
formed, should be below the knee. 

In cases of eczema of the prepuce the patient should dry the 
end of the penis, after each act of micturition, with lint or 
antiseptic cotton, and employ Boric acid ointment or lotion. 
It is well to prevent this complication by drying the end of 
the penis, as above, before eczema appears. 

Cystitis requires internally Urotropin, Salol or Boric acid, 
together with washing of the bladder with Boric acid (fifteen 
grains to the ounce) or of Salicylate (thirty grains to the 
ounce), to which hot water is added. Helmitol, internally, 
may be tried. 

Boils and Carbuncles require lint compresses moistened 
with Boric acid locally, or antiseptic poultices, as of linseed 
meal stirred in boiling water, ten ounces, to which two 
drachms of Carbolic acid have been added. 

Brewer's yeast should be tried as a remedy internally, or 
Quinine sulphate in three-grain doses four times daily. 

Flatulence and intestinal catarrh may require Fairchild's 
Pepules of Pancreatin, Nux and Ox-gall, or Creosote or Thy- 
mol. The Caroid tablets are particularly good for flatulence. 

Pulmonary tuberculosis requires a large quantity of fatty 
food, cod-liver oil, and a small quantity of alcohol. Other- 
wise, the general treatment is anti-tubercular. 

Arteriosclerosis, in association with diabetes, requires regu- 
lation of the bowels and the Iodide of Sodium internally. 

Nephritis, as a complication of diabetes mellitus, requires 
the following : Nitrogenous food in medium quantity, milk 



586 DIABETIC COMA. 

or Koumiss in large quantity, fatty food freely, bread in 
limited amount, but no sweets. The remedies are Potassium 
or Sodium citrate. The bowels should be caused to move 
freely. 

DIABETES MEEEITUS IN THE SEVERE FORM. 

This form is characterized by the appearance in the urine 
of a substance or substances giving a wine-red color, with so- 
lution of ferric chlorid, and by a toxaemia in the patient 
which terminates in diabetic coma. It must be remarked, 
however, that this red reaction is found in the urine of most 
diabetics under thirty from the very start. In older persons, 
however, the reaction may be absent for many years. 

Substances Causing the Reaction. — According to some 
authorities the substances present are acetone in excess, ethyl- 
diacetic acid, and lsevorotatory oxybutyric acid. 

According to Charles Piatt, ^-amidobutyric acid, CH 3 , 
CH, NH 2 , CH 2 , COOH, together with similar, but as yet un- 
determined substances is. the cause in the blood of diabetic 
coma and its allied manifestations. This substance is excreted 
in the urine as /?-hydroxybutyric acid. Its presence is due 
to the destruction of body-albumin. 

DIABETIC COMA. 

Pathology. — Only two theories of the cause of diabetic 
comaappear tenable : First, that of acidosis or acid intoxica- 
tion (Stadelmann), and second, that of a specific toxemia 
(Klemperer, von Noorden). The second is regarded by A. 
Mayer as really a continuation of the first. 

Etiology of Coma. — The etiology is obscure, but certain 
causes appear to be demonstrable as follows : 

i. Fatigue, whether from a long railway journey or exces- 
sive muscular exertion. 



ETIOLOGY AND ONSET OF DIABETIC COMA. 587 

2. Emotional disturbance. 

3. Sometimes from sudden change of diet. It occurs, 
however, regardless of diet. 

4. Prolonged constipation. 

5. Exposure to cold ; alcoholic, and sexual excess. 

6. Intercurrent affections, as pneumonia, influenza, car- 
buncles, abscesses. 

7. Administration of anaesthetics, surgical operations, oc- 
casionally operations for cataract. 

Diagnosis of Coma. — The premonitory symptoms are as fol- 
lows : 

1. Epigastric pain and nausea. 

2. Rapid pulse action. 

3. Dyspnoea. 

4. Drowsy mental condition, often with restlessness. 

5. The red reaction in the urine with ferric chlorid. 

6. The small opaque, grayish deposit containing large 
numbers of grayish granular casts. Fatal coma especially is 
announced by the presence of these casts. 

Onset. — Three classes of cases are encountered in diabetic 
coma : 

(1) The patient becomes weak, has syncope, becomes 
somnolent and gradually unconscious. In this class of cases 
death takes place in a few hours. 

(2) The patient has premonitory symptoms, as gastric 
crises, pharyngitis, phlegmonous affections, or lung troubles ; 
headache is noticed, followed by delirium, distress and 
dyspnoea. Death takes place in from one to five days. 

(3) The patient is seized with a sudden headache and diz- 
ziness and rapidly goes into coma. 

There may be abortive forms with quick recovery, but re- 
peated attacks ensue and prove fatal. In a very large number 
of cases coma follows exhaustion or over-exercise and is fatal 
in a few hours, rarely in three or four days. In few cases dia- 
betic circulatory collapse, so called, takes place or leads to 



588 DIABETIC COMA. 

coma. In old persons coma is likely to follow gangrene or 
carbuncles. 

Clinical Features of the Onset. — It may be said in general 
that any sudden improvement in objective signs not confirmed 
by subjective sensations on part of patient should put the phy- 
sician on his guard ; reduction in the excessive appetite to 
below standard for healthy person ; unexpected and unex- 
plained loose movements when constipatiou has previously 
been the rule ; peculiar fruity odor to breath already de- 
scribed ; acid eructations and nausea, with or without vomit- 
ing ; the patient complains of general prostration and disin- 
clination to exertion ; tendency to drowsiness during the day 
and great despondency ; attacks of intense vertigo, frontal 
headache, neuralgic pains ; accelerated pulse, with or without 
decrease in volume. After a variable period of indefinite symp- 
toms like the above the patient will complain of a feeling of 
depression, is restless at night, eats nothing, has colicky pains, 
vomits matters sometimes having fruity odor, has sense of 
constriction about the thorax, causing deeper breathing than 
usual ; mental condition varies from excitability to mild, 
talkative delirium, alternating with drowsy or stupid inter- 
vals. In some cases there is great anxiety and severe de- 
lirium. 

The essential features, clinically, are the gastric crises, 
which are followed by great weakness, from which the pa- 
tient may not rally. 

Dr. F. Hirschfeld, of Berlin, thinks that a typical case is 
easily recognized. A diabetic who has been feeding quite 
well notices gastric symptoms ; a violent headache sets in 
and a sensation of dyspnoea. These symptoms gradually in- 
crease in severity, the respiration becomes deeper and more 
rapid, the sensorium becomes confused, the patient slowly 
loses consciousness, and in two to ten days after the appear- 
ance of the first symptoms death occurs. 

Abortive forms frequently are noticed, where one or more 



CLINICAL FEATURES OF DIABETIC COMA. 589 

symptoms are pronounced, so that a suspicion of grave coma 
is aroused, but the symptoms disappear in a few days. The 
excretion of acetone is also increased here. 

Clinical Features. — During coma the following are 
noticed : 

Dyspncea. — A most characteristic symptom, becoming 
more extreme with increase of the coma, although the num- 
ber of respirations may be normal or only slightly increased 
in some cases, or in others respiration may be rapid, deep, and 
noisy. The patient is sometime cyanotic. The breathing has 
a peculiar panting or sighing character. There is fruity odor 
of the breath and urine. The breath is cold. The peculiar 
odor appears sometime before coma. 

Heart action much accelerated, pulse small and weak, fre- 
quently 1 20 or 130, and finally, 160 or more. The tension is 
low. Rapid pulse is regarded as an important early indica- 
tion. 

Temperature rarely increased, may sink as low as 86° or 
even lower. Occasionally it may rise at the last very high. 

Loss of conscious sensation common in all cases. 

The bowels are generally constipated, especially before the 
onset. Occasionally diarrhoea precedes. 

Livid face, or pale, cold face. The nose, lips and ears are 
slightly cyanotic and very cold to the touch. 

The pupils may be normal and may react to the light, 
though sluggishly. The eyelids are half closed. 

The surface of the body and extremities may be cold, but the 
patient, if conscious, may not feel cold. Hands and feet may be 
slightly cyanosed. 

Death may take place in twenty-four hours or less from the 
beginning of the attack. 

The Urine in Coma. — The quantity may in some cases de- 
crease and sugar diminish or be absent. The writer has, 
however, seen cases in which this did not happen until just 
before death, and in some instances has no record of its hap- 



590 DIABETIC COMA. 

pening at all. But the Bordeaux-red color with ferric 
chlorid is marked in all cases which the writer has seen. 

The ferric chlorid reaction is thus performed by the writer : 
Take two test-tubes of the same size and pour into one about 
4 or 5 c.c. (one fluidrachm) of the diabetic urine and into the 
other the same amount of normal urine. Make up a 20 per 
cent, solution of ferric chlorid, Fe 2 Cl 6 , in distilled water, 
Using a medicine-dropper with rubber nipple, add three or 
four drops, but not more, of the 20 per cent, ferric chlorid 
solution to each of the samples of the urine previously 
measured out into two test-tubes. (If a graduate is not at 
hand for the measuring purposes, about an inch of urine in 
each tube will be a proper amount.) 

The ferric chlorid solution should be dropped into the 
urine slowly, drop by drop, and fairly and squarely, so that 
each drop hits the urine and not the side of the tube. As the 
drops sink to the bottom they make a cloudy trail, due to 
precipitation of the phosphates. After the third or fourth 
drop has been added the upper and greater part of the urine 
becomes cloudy, but the bottom part is clear. Now, in nor- 
mal urine this clear bottom part is a golden-yellow color, but 
in urine containing diacetic acid the color is a more or less 
dark-red. 

When it is known with certainty that the patient is not 
taking drugs, the test as above described is sufficient. In 
these days of analgesic remedies, however, it is not always 
safe to assume that the patient has has not had a finger in the 
pie of his own treatment. The numerous aches and pains of 
diabetics are conducive to resort to the various analgesics, 
and it is precisely these substances which may make the test 
uncertain. 

When, therefore, we are not absolutely certain that the pa- 
tient is not taking drugs at the time the urine is examined, 
further procedure is necessary, as follows : Four or five c.c. 
(about one fluidrachm, or about one inch of urine in a test-tube 



THE FERRIC CHLORID REACTION. 591 

of medium size) are measured out and boiled over a spirit- 
lamp. The ferric chlorid is added precisely as before while 
the urineis hot, and the mixture immediately filtered. In case 
the red reaction noticed in the first test was due to diacetic 
acid and not to drugs, the urine now comes through the filter 
golden-yellow instead of red, and remains yellow, even after 
further addition to it while hot of a drop or two more of the 
ferric chlorid. 

If, on the other hand, the red reaction was due to the pres- 
ence of drugs in the urine, the filtered urine is reddish or will 
become red after further addition of a drop or two more of 
the ferric chlorid. 

I have made a sufficient number of experiments on the 
urine of diabetic patients to satisfy myself that the red color 
due to presence of drugs, as salicylates, in the urine will ap- 
pear when ferric chlorid is added to the hot urine, but will 
not appear in the hot urine when the color in the cold was 
due to diacetic acid. The results of the test may be shown 
concisely in the following : 

A. An inch of cold urine in a test-tube to which are added 
three or four drops of the 20 per cent, solution of ferric 
chlorid : (1) If the lower and clearer portion is a golden-yel- 
low color the test is negative. (2) If the lower and clearer 
portion is reddish or dark-red, either (a) diacetic acid is pres- 
ent or (b) some drug which gives a red color with ferric 
chlorid, or else other fatty acids, are present. 

B. In case the red color appears at the lower part, take an- 
other sample of the urine, boil an inch of it in a test-tube, add 
three or four drops of the ferric chlorid solution, and filter 
hot : (1) If the urine goes through the filter golden-yellow, 
and does not turn red when a drop or two more of the ferric 
chlorid is added to it, diacetic acid is probably present. 
(Further tests may be made as directed on page 233 of my 
work on the Urine.) (2) If the urine goes through 'the filter 
reddish or yellowish-red, or if the latter becomes more red 



592 DIABETIC COMA. 

when a drop or two of ferric chloric! are added to it, diacetic 
acid is absent, and the original red color in the cold urine was 
due to drugs or other substances. It is, of course, possible 
that a patient with diacetic acid in his urine might be taking 
salicylates or other drugs, in which case the conclusion that 
diacetic acid was absent would be erroneous. When, there- 
fore, the red color persisting in the hot urine is obtained, ad- 
ministration of drugs should cease until the absence of diacetic 
acid be assured. In other words, two points are essential to 
be made in the detection of diacetic acid : 

I. A red color when cold urine is treated with ferric chlorid 
solution. 

II. Absence of this red color when hot urine is similarly 
treated. 

After using this test as above for years without notable dif- 
ficulty, the writer not long ago ran across a case in consulta- 
tion in which the urine of a diabetic young woman gave the 
red reaction in both cold and hot urine. It was insisted upon 
that no drugs were being taken by the patient, and she died 
comatose about two weeks later. Owing to circumstances, I 
was never able to follow this case up by repeated analyses 
and ascertain the cause of the apparent anomaly. 

The substances other than fatty acids, which yield a similar 
reaction with ferric chlorid, are the Salicylates, Antipyrin, 
Thallin, Phenocoll, Salipyrin and Chloralamide. The sali- 
cylate reaction is violet or purple, but the other substances 
give a tint closely resembling that obtained from the fatty 
acids. 

[So many patients take coal-tar compounds that it is highly 
desirable that some clinical test other than the ferric chlorid 
should be discovered. Several methods for the detection of 
diacetic acid in urine have been proposed, notably those of 
Ivipliawsky and of E. Riegler. Riegler's test is comparatively 
simple : Half an ounce of urine (15 c.c.) is acidulated with 
from five to ten drops of concentrated sulphuric acid ; further 



THE URINE IN DIABETIC COMA. 593 

add two or three cubic centimeters of an aqueous solution of 
iodic acid ; an intense pink color will appear if diacetic acid 
is present. The color is not taken up by chloroform. It is 
claimed that this test is reliable and more delicate than the 
ferric chlorid.] 

The acidity of the urine undergoes marked increase. A 
pinkish color is sometimes noted. The odor is fruity in nearly 
every case. 

A small amount of albumin is generally present, and great 
numbers of grayish granular casts. 

The urine may be suppressed just before death, and remain 
so in spite of all treatment. 

Williamson and Kiilz regard the appearance of casts as a 
valuable premonitory sign of coma. In two cases which the 
writer has seen casts were found for the first time half a day 
only before fatal coma. 

Forms of coma known as alcoholic (resembling alcoholic 
intoxication) and diabetic collapse occur. 

In the alcoholic form the patient feels as if intoxicated ; his 
gait becomes unsteady, he becomes drowsy and gradually 
comatose. 

In diabetic collapse the patient suddenly begins to suffer 
from drowsiness and great weakness; the extremities are cold, 
the hands, feet and face livid, the pulse quick, small and 
thread-like, 120 or 130; respirations are shallow, there is not 
much dyspnoea, the temperature gradually falls, the skin be- 
comes covered in some cases with perspiration, the patient 
becomes more drowsy and finally comatose, and finally death 
occurs from collapse in ten to twenty hours. There is no re- 
action with ferric chlorid in the urine, nor any fruity odor. 
It occurs in chronic cases, often associated with gout or ne- 
phritis, and is due to mental or physical overexertion or error 
of diet. 

Differential Diagnosis. — The fruity odor of the breath and 
the urine, the red reaction in the urine with ferric chlorid 

38 



594 DIABETIC COMA. 

and the methylene bine reaction of the blood distinguish 
diabetic coma, especiall / if the patient is much wasted and 
sugar is found in the urine in appreciable quantity. In one 
of the writer's cases four per cent, of sugar was still present 
in the urine just as the patient was beginning to become 
drowsy. 

A close similarity is offered by poisoning by Salicylic acid 
in diabetics, yet here the symptoms will only last a few 
hours. 

Again, the attacks of heart weakness which are observed 
in diabetics after severe exertion may be easily confounded 
with diabetic coma. However, examination of the urine for 
acetic, diacetic and oxybutyric acids will be a certain guide 
as to the condition. This diagnosis is important, as these 
conditions of exhaustion are more easily treated than the 
terminal stage of diabetic coma. 

A much more difficult task is to decide whether apoplexy 
has complicated diabetes. For example, Hirschfeld has ob- 
served a diabetic in whom apoplectic state with an isolated 
paralysis was present. The patient had previously had several 
apoplectic seizures, with isolated paralysis, and examination 
of the urine revealed neither acetone nor diacetic acid. 

Sometimes the abdominal symptoms, obstinate constipa- 
tion, and vomiting may be so prominently in the foreground 
that an obstruction of the bowels may be simulated. In all 
suspicious cases one should examine the urine. A sudden 
sinking of the blood-pressure may precede, occurring even 
ten days before death. 

Prognosis. — This is now unfavorable, and it is usually only 
a question of time how long the patient will live. 

The ferric chlorid test seems to be an important factor in 
the prognosis, as will be seen by the following table of some 
of the writer's cases, whose present condition is known with 
certainty : 



PROGNOSIS IN SEVERE CASES OF DIABETES. 



595 



Cases. 


First Seen. 


Ferric Chlorid 
Reaction. 


Present Condition of Patient. 


I. Mr. M. . . . 


1891. 


Absent. None 


Alive and attending to busi- 






now. 


ness. (1903.) 


2. Mrs. G. . . . 


Feb., 1895. j Absent. Not 
found at last 
examination. 


Alive. In fairly good health. 


3. Mr. P. . . . 


Feb., 1895. Absent 


No sugar present. Patient well 
and attending to business. 


4. Mr. K. • . 


April, 1895. j Absent. 


Amelioration prompt, but pres- 
ent condition unknown. 


5. Mrs. S. . . . 


Dec, 1895. jAbsent, and 
not found at 


Alive and in fairly good health. 






any time 








since. 




6. Mr. B. . . . 


May, 1896. 


Absent. 


No record. 


7. Mr. C. . 


June, 1896. 


Absent. 


Rapid amelioration. Relapse 
when treatment discontin- 
ued. Now better again after 
resuming treatment. 


8. Mr. M. . . . 


Sept., 1896. Absent. 


Rapid amelioration. Sugar 
easily controlled. 


(Mr. R. . . 


Dec. 23, '96. Absent. 


Patient suffering from gastric 


9 - 

( Mr. R. . . 




crises. 


Dec. 26, '96. Present. 


Died in six weeks. 


10. Boy igyrs.old 


April, 1897. [Present. 


Died in June, 1897. 


11. Mr. G. . . . 


April, 1897. Absent. 


Rapid amelioration. Discon- 








tinued treatment, and died 








in 1899. 


12. Mrs. T. . 


May, 1897. 


Present. 


No record. 


13. O.R.,girlof8 


Aug., 1897. 


Present. 


Died in one year. 


14. Mrs. R. . . . 


April, 1895 


Present. 


Died in 1899. 


15. Mr. H. . . . 


Jan., 1898. 


Absent. 


Alive. 


16. Mr. B. . . . 


March, 1898. 


Absent. 


Rapid amelioration. Sugar re- 
ported to be absent. 


17. Mrs. M. . . . 


1897. 


Absent. 


Case stationary until writer's 
mineral- water treatment 
taken, when rapid ameliora- 
tion. 


18. Mrs Mc. . . 


April, 1898. 


Slight reaction 
present. 


Died, June, 189S. 


19. Mr. Mc. . . . 




Absent. 


Alive. 


20. Mr. E. 


Sept., 1898. 


Absent. 


Alive. Rapid amelioration. 
Sugar absent in less than a 
week . 


21. Boyi9yrs.old 


Oct., 189S. 


Present. 


Died, March, 1899. 


22. Mrs. W. . . 


Nov., 1898 


Present. 


Died of exhaustion, June, 1899. 


23. Mr. E. • • • 


Jan. 19, '99. 


Absent. 


Rapid amelioration. Sugar de- 
creased from 4 per cent, to 
less than 1 per cent, in a 
month. In good condition, 
Juiy, 1903. 


24. Mr. B. . . . 


Dec. 30, '99 


Absent. 


Rapid amelioration. Sugar de- 
creased from 5 per cent, to 
less than 1 per cent, in about 
a month. 



596 



DIABETIC COMA. 









Cases. 


First Seen. Reaction. 

1 


Present Condition of Patient. 


25. Mr. M. . . . 


June 1, 1899. Absent. 


Remarkable amelioration. 








Sugar decreased from 7 per 








cent, to % of 1 per cent, in 








5 days. Died a year later. 


26. Boy of 18 . . 


Au g- 5. '99- \ Present. 


Case obstinate. After a 
month's treatment sugar 
still 6 per cent. Died in Jan. 


27. Mr. M. . . . 


Aug. 25, '99. Absent. 


Sugar reduced from 6 per cent. 








to less than 1 per cent, in a 








fortnight. 



Since writing the above the following has happened : 

Case 26. — A boy, of eighteen, was so convinced that the 
writer had cured him that he discontinued treatment and 
went to work. In midwinter, while on a wagon unloading 
material, he became suddenly unconscious, fell off the wagon, 
w T as carried home and died comatose in three days. 

CASE 25 was so rapidly relieved as to believe himself en- 
tirely cured and hence gave up precautions. As a result 
from fatigue in sight-seeing he became worse in October, the 
ferric chlorid reaction appeared and he died of coma about 
six months later. 

Two other cases of interest are not found in the table 
above : One was a fine, healthy looking young woman whose 
urine in September showed a slight reaction with ferric 
chlorid. She improved so much on diet as to believe herself 
cured and never consulted the writer again. About three 
months later she became so weak as to be unable to work and 
gradually sank into coma. The urine passed on the day be- 
fore death contained four per cent, of sugar, gave a deep-red 
reaction with ferric chlorid and contained albumin in small 
quantity and numerous gray granular casts. Suppression of 
urine took place in this case, no urine being passed in spite 
of vigorous measures for relief for twenty-four hours before 
death. 



PROGNOSIS IN SEVERE CASES OF DIABETES. 597 

The most hopeful case which the writer has seen is that of 
a boy, now fourteen years old, whose urine in September, 1901, 
had the fruity odor of acetone and gave an unmistakeable red 
reaction with ferric chlorid. By dint of methodical exercise in 
the open air (horseback riding) and careful dietary the fruity 
odor and red reaction disappeared in a few months, the sugar 
came down below two per cent, and at times was wholly absent. 

A prominent feature in the diet was lettuce, which was 
given him freely, with olive oil as a dressing. He has gained 
flesh and strength on a strict diabetic dietary, the only bread 
allowed being biscuits made from diabetic flour. It is now 
two years since sugar first appeared in his urine together with 
the substances giving the red reaction with ferric chlorid. 

The case is notable in that it is the only one which the 
writer has seen in which it has been impossible to obtain the 
red reaction for a period of months after it was once plainly 
visible. But the patient has by no means recovered. 

After coma sets in death usually occurs in from twenty- 
four to forty-eight hours. Recovery may take place for the 
time in some cases, but a relapse will soon take place with 
fatal termination. 

The coma does not, however, pursue the same course in all 
cases ; sometimes the patient may linger several days. Some 
patients do not have the early stage of mental excitement or 
anxiety, but become drowsy first, then comatose. 

Treatment. — When the red action with ferric chlorid is 
found, great care must be taken not to withdraw carbohydrates 
from the dietary too suddenly or completely ; fatigue from 
long railway journeys or overexertion generally should be 
avoided. The trip to Carlsbad should not be advised in such 
cases. Even as short a journey as from Chicago to Boston 
proved fatal to one of the writer's patients, who smiled at 
proffered advice warning against it. 

The utmost care should be taken to avoid prolonged con- 
stipation in these cases. 



598 DIABETIC COMA. 

As to diet, the quantity of meat, eggs and nitrogenous 
foods must be decreased, a moderate amount of bread and a 
small amount of potatoes allowed, fatty food and cream given 
freely ; even milk in small quantities may be allowed, but a 
milk diet must not be prescribed. 

A patient, who came to the writer after being put on a milk 
diet by another physician, was so weak as to be saved from 
speedy death only by the most careful measures. 

During the gastric crises milk is the only diet possible, 
mixed with imported Vichy water or taken in form of 
kumyss. 

Mayer thinks well of milk in cases where the patient is 
drowsy and coma threatening. He allows one quart in twenty- 
four hours. 

In general fatty foods, except during these crises, are to be 
preferred to the more highly nitrogenous diet usual in earlier 
stages. Alcoholic drinks, as whisky or brandy, in small 
quantity (one and one-half fl. oz.) may be of service in aiding 
the digestion of fatty foods or when the patient has a disgust 
for fat. The artificial cream above described should be given 
to patients in this stage. 

The medical treatment is as follows : As a rule, the first 
thing to do is to give a dose of castor oil ; if it fails to work 
a compound jalap powder may be given. 

The patient should drink water freely. Prolonged tepid 
baths are to be recommended. In cases of collapse, Ether,, 
Ammonia, Digitalis, and Alcohol are to be administered. 
Strychnine, Digitalis, or Ether, hypodermically, are most ser- 
viceable. Inhalations of oxygen should tried for symptoms 
of approaching coma. 

When the patient is not yet comatose, but is drowsy and 
troubled with dyspnoea, | alkalies in massive doses should be 
tried ; thirty grains of Sodium bicarbonate in a little milk 
every three hours and one hundred grains of Sodium citrate 
three times daily may sometimes prevent coma. The writer 



TREATMENT OF DIABETIC COMA. 599 

has seen a case in which, however, even these massive doses 
failed to prevent a rapidly fatal coma, and Williamson says, 
" Unfortunately, the comatose symptoms usually advance to a 
fatal termination in spite of alkaline treatment. 

Intravenous injections, when properly performed, have often 
a decidedly, though only temporary, beneficial effect after 
coma has once set in. The solutions used are Sodium 
chloride alone, with the Phosphate or Carbonate, or with 
both Phosphate and Carbonate of Sodium ; Sodium bicarbon- 
ate alone is sometimes used. Intravenous injections of 
Sodium chloride alone in the strength of 0.6 to 0.75 per 
cent, is used. Sodium bicarbonate is used in the strength of 
3 to 5 per cent. 

In some cases solutions of Sodium carbonate of the same 
strength have been used. Matthew's solution should be tried 
in these cases. 

Cases have been reported in which intravenous injections 
used in the early stages of coma have prevented the fatal issue. 
Lepine used in one case two liters (sixty-six ounces) of a 
solution containing seven grammes (108 grains) of Sodium 
chloride and ten (155 grains) of Sodium bicarbonate per liter 
(thirty-three fluid ounces). 

For intravenous injection all the apparatus necessary is a 
funnel and piece of India-rubber tubing with clips and can- 
ula. One of the veins in front of the elbow is exposed, and 
the canula inserted. It is important that the fluid used 
should not be cold. The solution of Sodium chloride or 
Sodium bicarbonate is mixed with an equal quantity of warm 
water just before being transfused. Repine recommends that 
the fluid injected should have a temperature of 100. 4 F. The 
fluid is apt to become cold if kept for a long time in the fun- 
nel whilst the vein is being exposed. Hence, it is better to 
expose the vein first before placing the warm fluid in the 
funnel and tubing. In place of a funnel a vessel may be 
used which has a cover, the fluid flowing from the lower part. 



600 DIABETIC COMA. 

For the early stages of coma a vapor-bath giyen in bed, 
and powerful stimulants, as Ether, Ammonia, Musk, Vale- 
rian, or Camphor, may ward off the attack. Sodium bicar- 
bonate in ten-grain doses may also be given. Intravenous in- 
jections of alkaline solutions have been tried, but without 
success, as a rule. Intravenous injection of normal salt solu- 
tion in early stages may postpone the attack. 

According to Swarz Gly conic acid neutralized with Sodium 
bicarbonate has repeatedly overcome diabetic coma. 

Mayer reports a case in which coma was repeatedly com- 
bated with success by use of Urotropin in doses of from 
twenty to sixty grains daily. His theory is that the drug- 
splits up into ammonia and formaldehyde in the body and 
that the ammonia neutralizes the fatty acids in the blood, 
while the formaldehyde passes out in the urine. He also be- 
lieves in large doses of alkalies, especially Sodium bicarbonate 
by all possible channels as much as the patient will stand ; 
as, for example, by mouth, by enema, or by subcutaneous or 
intravenous injection of a three to five per cent, solution. 

In all cases in which the red reaction with ferric chlorid is 
obtained, Naunyn suggests that Sodium bicarbonate be given 
daily for a long time in doses of from ten to twenty grammes 
(two to five drachms) per twenty-four hours. 

During the coma itself luke-warm baths and douching may 
be tried with hypodermics of Camphor or Ether. 

McCaskey, of Fort Wayne, believes in daily antiseptic irri- 
gations of both stomach and colon with intragastric faradism, 
abdominal massage, and general hot and cold douches. 

Guiranna (La Clinica Medic a, An. 5, n. 19) speaks very 
highly of a diet of fresh vegetables in the treatment of dia- 
betes. In bad cases he finds that much benefit is derived 
from an exclusive diet of fresh vegetables for a few days, but 
in ordinary cases a mixed diet is sufficient. The vegetables 
recommended are endive, cabbage, French beans, artichokes, 
and in general all green vegetables. Peas and beans, pro- 



DIABETES INSIPIDUS. 601 

vided they be fresh, may be taken in small quantities {% kil- 
ogramme). He also allows fruits in moderation. The only 
saccharine substance allowable is levulose, from 50 to 200 
grains a day. Probably the reason why green vegetables are 
tolerated so well is because the starch is converted into levu- 
lose and not dextrose. The objection to saccharin and dul- 
cein for sweetening is that they do not represent a food, but a 
foreign body in the organism. 

In support of this assertion is the case cited by the author 
above, in which forced feeding with lettuce seemed to be at 
least a factor in causing the disappearance of the red reaction. 

DIABETES INSIPIDUS. 

Definition. — A disease characterized by persistent polyuria, 
often excessive, without presence of sugar or albumin in the 
urine, and usually accompanied by polydipsia. 

Etiology. — The disease is thought to be a neurosis, having 
its origin in the dilatation of the renal arteries from paralysis 
or irritation of their vaso-motor nerves. 

The various exciting causes may be grouped as follows : 

1. Trauma, inflammation, or irritation of the brain, cere- 
bellum or medulla ; sunstroke, cerebral tumors and syphilis, 
myelitis, violent mental emotions. 

2. Heredity, occurring in families. 

3. Tubercular meningitis, epilepsy, hereditary syphilis ; as 
sequela of acute infectious diseases, and in scurvy ; in sac- 
charine diabetes after disappearance of sugar ; as a result of 
excessive drinking ; in young children from drinking alco- 
holic liquors. 

4. Exposure to cold and drinking cold fluids when heated ; 
abuse of diuretics. Inveterate masturbation, incontinence of 
urine, and tape-worm. 

5. Abdominal tumors, especially near coeliac plexus, and 
chronic inflammatory processes in same region. 



602 DIABETES INSIPIDUS. 

The etiology is probably unknown. Clinically we find it 
most commonly excited by emotional disturbance, concussion; 
or injury to the brain or body ; syphilis, or previous acute 
disease as typhoid fever, malaria, cerebro-spinal meningitis, 
influenza or syphilis. 

Occurrence. — Occurs in males more often than in females, 
more frequent in the first half of life, and may occur even in 
young children. In fifty per cent, of Roberts's seventy cases 
the patients were under twenty, and in ten per cent, infants. 
Only four cases out of the seventy were over fifty years of 
age. 

In the writer's experience the disease is a rare one, occur- 
ring not half a dozen times in nearly 6,000 cases of all sorts 
examined. 

Like diabetes mellitus it may attack members of the same 
family. 

One-fifth of all the cases reported occur in children under 
ten years of age. It has been reported in a child as young as 
three or may apparently be congenital. 

It may alternate in families with central neuroses, as hys- 
teria, epilepsy, neurasthenia, psychopathy, and occasionally 
with diabetes mellitus. 

It may be due to the toxic influence of digitalis or other 
diuretics, alcohol and lead. 

Symptomatically it may be a result of diseases of the 
nervous system, as softening of the brain or new growths in 
the floor of the fourth ventricle near the glycosuric point. 

It may be associated with neurasthenic symptoms, insomnia 
and chorea. . 

Post-Mortem Appearances. — Lesions of the brain and 
nervous system, as in the floor of the fourth ventricle, are 
found in some cases, and in the vicinity of the cceliac plexus 
in others. The kidneys are enlarged, and in certain cases 
the pelves and ureters dilated and the bladder hypertrophied. 

It is held that the cases in which tumors or inflammatory 



CLINICAL FEATURES OF DIABETES INSIPIDUS. 603 

changes in the medulla or cerebellum are found, together with 
exostoses at the base of the brain, are those of symptomatic 
polyuria rather than true diabetes insipidus. 

Onset. — It may begin immediately after drinking a large 
amount of fluid, as on a hot day after a long march, or as re- 
sult of injury, or may begin gradually. 

Cases are known in which the disease is congenital. 

It usually begins with headache, vertigo, a feeling of ma- 
laise, irritability, disturbed sleep and alterations in the ap- 
petite. 

Clinical Features. — These are essentially the following : 

i. Polyuria, which may be excessive, one or two gallons, 
even, of urine being voided in 24 hours. 

2. Excessive thirst, polydipsia. 

These may be the only features in the mild cases. In 
severer cases we find : 

3. Dry, harsh, hot, shrivelled and scaly skin ; dry mouth 
and throat. 

4 Headache, vertigo, mental symptoms, neuralgia. 

5. Loss of strength and of flesh, weakness of the pulse. 

In cases where the amount of solids voided is not in excess 
of normal, the patient feels poorly, is easily chilled, appetite 
is capricious, and there is a sinking, gnawing sensation in the 
pit of the stomach. 

When cerebral lesions are present, disturbances of sensi- 
bility or of motion occur. Headache or convulsions may 
occur. Ptyalism has been noticed in several cases. 

The amount of urine voided may exceed the amount of 
fluids ingested 

Furunculosis is rare. Cataract is less common than in dia- 
betes mellitus, as is also pulmonary tuberculosis. The appe- 
tite is not excessive. The bowels are regular or but slightly 
constipated and gastro-intestinal disturbances are not marked. 

The sexual function is not disturbed. The temperature is 
normal or slightly subnormal, perhaps on account of the 
drinking of much cold water. 



604 DIABETES INSIPIDUS. 

In severe cases the patient becomes emaciated, languid, 
feeble and loses inclination to exertion. The sleep is dis- 
turbed and the mind depressed. The patient is irritable and 
nervous. 

The knee-jerks are enfeebled or absent. 

Neuroretinitis and paralysis of the ocular muscles may be 
present. 

The bodily temperature is low and the patient feels chilly. 

Osier mentions tolerance of alcohol as a marked feature of 
diabetes insipidus ; the patient may be able to drink two pints 
of brandy in a day or a dozen bottles of wine. 

The Urine. — We find two forms of this disorder, namely, 
hydruria and polyuria. In hydruria the quantity of urine per 
twenty-four hours is enormous, and the specific gravity be- 
low 1008. In polyuria the quantity of urine, though not 
enormous, is greatly increased, and the specific gravity 10 10 
and upwards. 

The total urine per twenty -four hours is usually that of 
fluids ingested ; but if the fluids be cut off the urine is not 
diminished proportionately. The volume of urine per twenty- 
four hours is generally greater than that of diabetes mellitus. 
Very young children have been known to void as much as 
thirty pints in the twenty-four hours. Roberts speaks of a 
girl of ten who voided a little more than a third of her own 
weight of urine. Ten to fifteen pints daily (5000 to 7500 c.c.) 
is not uncommon in the case of children afflicted with this 
disease. 

Boggess reports a case in which a colored girl of eleven 
drank from seven to nine gallons of water during the twenty- 
four hours and passed about the same amount of urine. The 
specific gravity of the urine was about the same as that of 
water. 

The total solids are, as a rule, above normal per twenty- 
four hours, though decreased relatively (grains per ounce, 
grams per liter). 



DIAGNOSIS OF DIABETES INSIPIDUS. 605 

In some cases, without great increase in twenty-four hours' 
urine, the total phosphoric acid is double or treble the normal 
per twenty-four hours (phosphatic diabetes) and the urea- 
phosphoric acid ratio diminished. 

Albumose, hippuric acid and inosite may occur in the 
urine. 

Physical Characteristics. — We find feebly acid urine which 
readily decomposes and then deposits a creamy-white sedi- 
ment of amorphous phosphates. Color and odor deficient. 
Appearance clear when voided, soon becoming cloudy from 
presence of micro-organisms. Sediment scanty, containing 
nothing of significance. 

In case various intercurrent disorders appear, the urine may 
be considerably diminished in amount. 

Cases are known in which excessive elimination of phos- 
phoric acid occurs. In these cases, although sugar is absent, 
there is, in addition to the symptoms mentioned above, a 
tendency to boils, ravenous appetite, possibly cataract, as in 
the case of diabetes mellitus. This kind of diabetes insipidus 
is called phosphatic diabetes and is associated sometimes with 
nervous derangements or with phthisis, sometimes with 
neither. Again, in some cases excessive elimination of the 
chlorides may be noticed (chlorine diabetes). 

Diagnosis.— The determining points are an excessive poly- 
uria, polydipsia, and weakness, as in diabetes mellitus, but the 
polyuria averages greater and there is no sugar in the urine 
and the specific gravity is low. On depriving the patient of 
water, if the urine decreases in amount, the disease may be 
regarded as primarily polydipsia, but if not, polyuria. 

Course. — Uncertain. Congenital cases may last fifty or 
sixty years. Recovery, when it takes place, is usually in one 
or two years from time of onset. 

The disease may merge into diabetes mellitus. The course 
is usually chronic and long. 

Differential Diagnosis. — The conditions which are to be 
differentiated are as follows : 



606 DIABETES INSIPIDUS. 

i. Hysterical polyuria. 

2. Chronic interstitial nephritis. 

3. Hydronephrosis.- 

4. Convalescence from acute nephritis, especially post- 
scarlatinal, and from other acute diseases. 

5. Neurasthenic polyuria. 

6. Polyuria in women with pelvic congestion and consti- 
pation. 

7. Diseases of the medulla and cerebrum with polyuria ; 
chronic hydrocephalus with polyuria. 

8. Polyuria from use of diuretics as in dropsy and from ab- 
sorption of serous effusions. 

Diabetes insipidus is distinguished from the first by its per- 
sistence ; from the second by absence of cardio-vascular 
changes and of albuminuria and cylindruria ; from the third 
by persistence, and absence of tumor diminishing in size, 
with abundant flow of urine ; from the fourth by the history, 
absence of albuminuria and cylindruria, and presence of per- 
sistent excessive polyuria. 

Neurasthenics may void considerable urine of low specific 
gravity, but a quantity over five pints is not usually a per- 
sistent symptom, nor is there usually the thirst found in 
diabetes insipidus. 

Women who have pelvic congestion and are constipated 
void a good deal of urine, but not an enormous quantity ; 
moreover, the night urine is likely to exceed the day very 
considerably. 

In general diabetes insipidus maybe distinguished by the 
enormous flow of urine which is usually in excess of fluids 
ingested. 

Eichhorst describes cases of diabetes insipidus occurring in 
connection with certain specific infectious diseases, such as 
diphtheria, cerebro-spinal meningitis, measles, scarlet fever, 
etc. These must be distinguished from the cases of transient 
polyuria described by Spitz, which occur during conva- 



PROGNOSIS IN DIABETES INSIPIDUS. 607 

lescence after certain specific fevers, especially typhoid. In 
these last cases the polyuria lasts from six to eight weeks, 
and is not accompanied by polydipsia. 

Prognosis. — Death is rare from the disease itself, which 
may last a lifetime. The danger is from other disorders, es- 
pecially phthisis, pleuro-pneumonia, carcinoma, or organic 
disease of the brain. In syphilitic cases the prognosis de- 
pends on the curability of the syphilis. 

Cases beginning suddenly may run an acute course and 
may die within a few months, though, doubtless, not of the 
disease itself, but of the lesion causing it. 

The condition of the urine is to be considered ; if urea and 
phosphoric acid are not in great excess, the patient being 
well cared for and without hereditary taint, it is possible that 
he may live as long as otherwise. If, on the other hand, there 
is a marked increase of urea and phosphoric acid, suspect the 
condition to be but a prelude to serious constitutional dis- 
turbance, and give ultimately unfavorable prognosis. In some 
cases nervous disorder or phthisis appears ; in others, diabetes 
mellitus. Albumin in appreciable quantity is an unfavorable 
sign, as is also oedema of the feet. In one case which I saw, 
apparently congenital, at the age of sixteen, I found albumin 
in the urine ; two years later casts appeared, the patient be- 
came more or less cedematous, and died of uraemia. 

It must be remembered, however, that a mere trace of al- 
bumin is quite often found in the urine of not only this dis- 
ease, but of diabetes mellitus as well, perhaps due to irrita- 
tion of the kidneys. It does not necessarily signify nephritis. 

Children may succumb to exhaustion, caused by loss of 
rest, tormenting thirst, and mental worry. 

Death often is the result of exhaustion, pulmonary disease 
or intercurrent affections. In general, the prognosis is usually 
unfavorable and recovery rare. In some cases the disease be- 
comes stationary and the patient lives to be old in spite of it. 

The hereditary congenital variety may not be serious. 



608 DIABETES INSIPIDUS. 

Cases have been known where the disease was apparently 
congenital in different members of the same family, most of 
whom lived to old age. 

Spontaneous cure may occur in some cases. 

Treatment. — Everything which aggravates the condition 
must be sought for, and if possible removed ; inveterate mas- 
turbation, enuresis, tape-worm, and hereditary syphilis must 
not be overlooked. Phimosis and rectal diseases should re- 
ceive attention. 

When the patient is not voiding too much urea, give food 
and drink liberally, seeing to it that drinks are not too cold. 
The various drinks may be thickened, as, for example, by the 
use of a handful of raw oatmeal to a quart of boiling water, 
with a lemon sliced into it. Warm woollens should be worn, 
and the patient, if possible, spend winters in a warm, dry 
climate. Salt-water douches are sometimes useful in promot- 
ing bodily vigor. Warm baths, followed by friction of the skin 
with coarse towels, are beneficial. 

In cases where urea is increased relatively to the weight of 
the patient, nitrogenous food is to be limited. Alcoholic 
drinks and coffee are not allowed. Vapor-baths, followed by 
salt-water tepid douches, are recommended and a dry, bracing 
climate sought. Hygienic care and regulations, as in diabetes 
mellitus, ordinary warm baths, followed by friction of the 
skin with coarse towels, are often found beneficial. 

For the thirst, hot alkaline mineral waters, as Allouez, 
should be tried. 

The amount of water taken should be gradually reduced 
and methodical physical exercise practiced. 

Symptomatic Treatment. — Strychnine phosphate. — Useful 
for the various nervous symptoms, as weakness, depression of 
spirits, irritability, etc. Use the second decimal. 

Ferrum. — In anaemic cases, indications already given. Use 
Ferrum phos. in the second decimal. 

Scilla. — In cases where there is an inordinate quantity of 
pale urine. 



TREATMENT OF DIABETES INSIPIDUS. 609 

Apocynnm. — In cases where there is a marked sensation of 
sinking in the epigastric region. 

Helonias. — Abnormal languor, feeling of weakness and 
weight in the region of the kidneys, general weariness ; the 
patient wakes in the morning with lips, tongue and fauces 
dry, and a bitter, disagreeable taste in the mouth ; pain and 
feeling of lameness in the whole back ; numbness in the feet 
relieved by motion ; chill ; gloomy and irritable mental con- 
dition ; profound melancholia. 

Secale is indicated when great thirst predominates, and par- 
ticularly when there is lack of contractile force in the tissues. 

Rhus aromatica is useful when there is persistent enuresis. 

Thuja may quickly relieve cases where there is frequent 
urination with heat and a burning desire to urinate again 
soon after the bladder is emptied. Given by Waterhouse in 
drop doses (Lloyd's tincture) in glycerine. 

In cases depending upon incurable brain trouble we cannot 
expect relief from symptomatic or other treatment. 

Palliative Treatment. — Those remedies already mentioned 
under diabetes mellitns are frequently indicated in this dis- 
order. 

In anaemia and debility, cod-liver oil and the Iodide of Iron 
will help debilitated children with diabetes insipidus. In 
syphilitic cases, Iodide of Sodium and mercurial inunctions. 

Jambul will undoubtedly, in some cases, decrease the quan- 
tity of urine, but its action is at best but imperfectly under- 
stood, and it is said not to be efficacious with the patient 
on a mixed diet. 

Sodium bromide is believed by Purdy to have arrested two 
cases ; he thinks that the drug should be given in doses large 
enough to affect locomotion, and then decreased to a point 
just short of affecting it. In some cases the constant galvanic 
current has been found beneficial. Purdy says that the best 
results are said to follow the application of the positive pole 
to the cervical region over the vertebra, and the negative pole 
to the lumbar region and pit of the stomach alternately. 
39 



610 DIABETES INSIPIDUS. 

Ergot appears to have cured some cases. The doses rec- 
ommended are 60 to 120 minims of the fluid extract for an 
adult. 

Miscellaneous. — Claims are made of cures by the following 
agents : Potassium iodide and Mercury (dose not given) re- 
duced the urine of a child of six from thirty pints to four 
(Demme); combined use of Antipyrin, 0.5 gramme (7^ 
grains) three times daily, powdered Valerian root three times 
daily, and galvanism to the cervical sympathetic and to the 
spine, cured a case in a boy of twelve years, who voided 
13,700 c.c. in twenty-four hours, with specific gravity less 
than 100 1 (Zeuner). 

Extract of Ergot (ten grains in capsule three to six times 
daily), Zinc valerinate (one or two grains in capsule three or 
four times a day) are deemed effective. 

It is held that the dose of these agents should be increased 
until some therapeutic or physiological effect is produced. 

W. F. Clark claims success in diabetes insipidus from in- 
gestion of suprarenal glands. 

For the thirst and polyuria Opium is said to be helpful 
given in the form of laudanum ; dose, fifteen to twenty drops, 
several times daily. 

Anders thinks that Ergot is the best remedy, next the Bro- 
mides and Acetanilid given alternately at intervals of a couple 
of weeks. 

Static electricity may be of assistance in reducing the 
quantity of urine. 

In nervous polyuria in women static electricity is worth 
trying. 



. CHAPTER XXL 

CLINICAL MEMORANDA AND SUMMARY. 

The Mortality in Five Hundred Cases of Albuminuria. — 
What is the significance of albuminuria ? With view to ob- 
tain data by means of which this question may be answered, 
I have looked up the present condition of 800 persons in 
whose urine at one time or other I had found albumin, and 
300 persons in whose urine I had never found albumin. 

I have succeeded thus far in tracing 558 of the albuminurics 
and 253 of the non-albuminurics. 

The statistics of mortality among them are as follows : 
From January 1, 1888, to January 1, 1895, 126 out of the 558 
albuminurics have died, or about 23 per cent.; 28 out of the 
253 non-albuminurics are dead, or about n per cent. 

The percentage of mortality, then, among the albuminurics 
is more than double that among those in whose urine albumin 
was not found. 

The test for albumin which I have used is Ultzmann's, viz., 
filtering, boiling upper third, add three to six drops of 20 per 
cent, acetic acid ; more if the urine is alkaline, less if not. 

Is the mortality among all classes of albuminurics the 
same ? In answer to this question my statistics show the fol- 
lowing : Albumin, without tube-casts of any kind (save pos- 
sibly so-called mucous casts), occurred in the urine of 255 per- 
sons out of 558, and of these 255 only 37 are dead, a mor- 
tality of about 14 per cent. 

In other words, the percentage of mortality among the al- 
buminurics without tube-casts is only 3 per cent, greater than 
that of those in whose urine no albumin at all was found. 
Pus, blood, bile, prostatic and seminal fluids, leucorrhceal ad- 



612 CLINICAL MEMORANDA AND SUMMARY. 

mixture, and twenty-four hours' urine, in which, from de- 
composing mucus, micro-organisms are numerous, are doubt- 
less factors in the albumin reaction, where it is obtained 
without presence of casts. 

So, then, the individual who says that his urine is " all 
right," because of absence of albumin and sugar, has not such 
overwhelming odds in his favor, over and above him in 
whose urine albumin alone, without casts, is found. 

What is the mortality among those in whose urine both al- 
bumin and casts are found ? There were 304 such persons in 
all out of the 558 albuminurics, whose present condition 1 
know with certainty, and of the 304, 89 are dead, or about 30 
per cent. 

In other words, where casts are found, together with albu- 
min, the mortality is nearly three times as great as in the 
non-albuminuric cases, and more than twice as great as in 
those who have albumin without casts. 

SUMMARY NO. I 1888-1895. 

I. Non-albuminuric cases whose present condition is known 

with certainty, , ... 253 

Deaths, • • • 28 

Percentage of mortality thus far, ... 11 

II. Albuminurics without casts, 255 

Deaths, 37 

Mortality per cent; thus far, 14 

III. Albuminurics with casts, 304 

Deaths, 89 

Percentage of mortality thus far, about 30 

What influence, if any, has the kind of casts found on the 
mortality ? Of the 304 albuminurics with casts of all sorts, 
177 were those in which the casts were either hyaline or epi- 
thelial, at any rate not granular, waxy, or fatty. Of these 177 
there are 36 dead, or 20 per cent. On the other hand, there 
were 127 persons in whose urine either granular, fatty, or 
waxy casts, or all three together, were found, and of these 127 
there are 53 dead, a percentage of 41, the highest of all thus 
far recorded. 



MORTALITY IN 500 CASES OF ALBUMINURIA. 613 

These figures would appear to show two things : First, 
that the occurrence of albumin, together with hyaline or epi- 
thelial casts, is not without significance. The mortality in 
such a condition is nearly twice as great as where neither al- 
bumin nor casts are found, and nearly once and a half as great 
as where albumin without casts occurs. [I recall that in 
several fatal cases albumin and hyaline or epithelial casts 
would be found for months or years, then suddenly granular 
casts would appear, perhaps not until within a few weeks or 
even days before death.] 

Second, whatever may be the alleged clinical significance 
of granular casts, and whatever may be the pathological 
theories founded on post-mortem examination, actual statistics 
show the following as regards mortality from 1888 to the 
present time, (when this paper was written), 1895 : 

In 1888 I saw one such case, a woman, in whose urine at 
the time of menopause granular casts were found by me. She 
died in a few months. 

In 1889, nine cases came under my observation. All were 
men, and four have since died. In other words, more than 
half were alive at the end of six years. 

In 1890 there were twelve, eight men and four women. 
Seven have since died, or 60 per cent. Of the dead, four 
were men, and three were women. In other words, a little 
more than half died in a space of five years, and a little less 
than half were still living. 

In 1891 I saw fourteen cases, thirteen men and one woman. 
Nine of them, all men, died, or 65 per cent., but one-third 
of the cases were still alive at the end of four years. 

In 1892 the total was thirty, nineteen men and eleven 
women. Twelve died, namely, seven men and five women, 
making a mortality thus far of 40 per cent. In other words, 
more than half were still alive at the end of three years. 

In 1893 I saw thirty-three cases, twenty men and thirteen 
women. Thirteen died, namely, seven men and six women. 



614 CLINICAL MEMORANDA AND SUMMARY. 

The mortality thus far is 40 per cent. More than half them 
were alive at the end of two years. 

In 1894 there were twenty-eight cases, twenty-four men 
and four women. Seven died up to January 1, 1895, namely, 
six men and one woman. The mortality thus far in these 
cases is 25 per cent. 

According to sex the figures are as follows : Total number 
of men, 93 ; women, 34 ; mortality among men, 37, or 40 per 
cent.; of the women 16 died, or 47 per cent. 

In how many of the fatal cases were the casts waxy or fatty, 
and in how many granular alone ? 

Typical well -pronounced fatty casts in which fat droplets 
could be seen were found in ten of the fatal cases, waxy casts 
in six, casts which would ordinarily be called granular* in 44. 

Finally, then, the finding of granular casts in the urine is 
by no means significant of rapid dissolution, not even in 
chronic cases, most of the cases above being of the latter 
variety. Five patients with granular casts were alive at the 
end of six years, 5 at the end of five years, 5 at the end of 
four years, 18 at the end of three years, 20 at the end of two 
years, 21 at the end of a year. Nobody knows, of course, for 
how long any of these had granular casts in their urine, or at 
what times or under what circumstances. 

Paying attention then solely to my figures and without re- 
gard to anything else whatever, if granular casts with albu- 
men are found in the urine, the patient has three chances in 
four of living one year, and about one chance in two of living 
two to six years. In other words, about half the patients in 
whose urine I have found granular casts have died in periods 
ranging from two to six years. 

It seems to me that this is a favorable showing when we 
consider of what dreadful portent the term " granular cast " 
has been in the past. 

* The writer is aware that many casts apparently granular, when seen 
with a high power, are really fatty. 



MORTALITY IN 500 CASES OF ALBUMINURIA. 615 

Care was taken in all these cases not to confound zoogloea 
masses of bacteria, deposits of urates or phosphates, or ex- 
traneous matters of any kind with casts, and in no case were 
the casts called granular unless unmistakably so. In several 
cases suspicious looking granular fragments or masses were 
encountered without the size, shape and appearance character- 
istic of true renal granular casts. Such cases have not been 
included in the category above. 

SUMMARY NO. 2. 

Albuminurias with casts, 304 

I. Without granular, fatty or waxy casts, 177 

Deaths, 36 

Percentage of mortality thus far, 20 

II. With granular, f itty or waxy casts 127 

Deaths, 53 

Percentage of mortality thus far, 41 

III. Mortality in those of II according to sex. 

(a) Total number of men, 93 

Deaths, . . 37 

Percentage of mortality thus far, 40 

(b) Total number of women, 34 

Deaths 16 

Percentage of mortality thus far, 47 



What bearing has urea on the mortality in cases of albu- 
minuria, together with granular, fatty or waxy casts ? 

Urea was estimated at one time or other in the 24 hours' 
urine of 28 persons who died. The smallest amount of urea 
in 24 hours was 90 grains (6 grammes), the largest, 415 grains 
(27 grammes). The average total urea in these 28 fatal cases 
was 210 grains (14 grammes) in 24 hours. The average total 
urea in 210 other cases, without albumin, casts or sugar, was 
350 grains (23 grammes). These 210 cases were picked up at 
random from my records and not selected with care. In other 
words, the average daily excretion of urea in the 28 fatal 



616 CLINICAL MEMORANDA AND SUMMARY. 

cases of persons passing albumin and granular casts was 
nearly 150 grains (10 grammes) less than that of 210 persons in 
whose urine neither albumin, casts or sugar was to be found. 

Taking 300 grains of urea (20 grammes) as a basis of con- 
sideration, 66 per cent, of the 210 persons just mentioned 
failed to void this quantity in 24 hours, whilst 85 per cent, 
of the 28 fatal cases did not excrete this quantity. 

What relation did percentage quantity of albumin bear to 
the mortality in cases of albuminuria with granular casts ? 

Observation of the percentage quantity of albumin was 
made in 49 fatal cases : 2 1 passed enough albumin so that 
from the specimen furnished the coagulated mass rose to the 
first mark, 1, on the Esbach tube or higher, the highest being 
to the mark 7. In 12 cases there was enough albumin to be 
noticed in the Esbach tube, but it failed to rise as high as the 
figure 1. In 16 cases but a trace could be found with Ultz- 
mann's test. 

In other words, in less than half the fatal cases when ob- 
servation of the quantity of albumin was taken, did the lat- 
ter occur in quantity sufficient to attract the attention of the 
general practitioner, and in one-third of the cases the chances 
are that the presence of albumin would not have been de- 
tected at all, except by one more than ordinarily familiar 
with urine testing. [I base this last supposition on observa- 
tion of the work of some 500 men to whom I have taught 
urinary analysis. It is only after a number of exercises that 
they can be depended on to detect what experts call a " plain 
trace " of albumin.] 

What relation did specific gravity bear to these case's ? The 
specific gravity of the twenty-four hours' urine was taken in 
forty -four of the fatal cases. It was 1,015, or less, in twenty- 
one cases, the lowest being 1,006. It was above 1,015 in 
twenty-three cases, above 1,020 in nine cases, above 1,030 in 
three cases. In other words, while it was below 1,020 in 
thirty-three out of forty-four fatal cases, or seventy-five per 
cent, it was above 1,015 in more than half the fatal cases. 



MORTALITY IN 500 CASES OF ALBUMINURIA. 617 

What observations were made on the quantity of urine for 
twenty-four hours ? 

In twenty-eight fatal cases the twenty-four hours' urine was 
collected and measured. Above fifty fluidounces (1,500 c.c.) 
occurred eight times ; between thirty-three and fifty fluid- 
ounces (1,000 to 1,500 c.c.) four times; between seventeen 
and thirty-three (500 to 1,000 c.c.) ten times ; less than one 
pint (500 c.c.) five times. The smallest quantity observed 
was about one fhiidounce (40 c.c.) in twenty-four hours. So 
then, twenty out of twenty-eight in the fatal cases passed less 
than three pints (1,500 c.c.) in twenty-four hours, and sixteen 
out of twenty-eight passed less than two pints (1,000 c.c). 

[This is in accord with my general observations on the 
urine of all diseases in Chicago and vicinity. Out of 1,300 
persons of all sorts, eighty per cent, voided less than three 
pints of urine in twenty-four hours, and nearly fifty per cent, 
less than a pint.] 

What relation did color of the urine bear to mortality ? 

I have already said* that a peculiar color appearing in the 
urine has been observed in certain fatal cases ; this color is 
best imitated by diluting the official solution of oxychloride 
of iron with water, usually about equal parts of each. This 
oxychloride color was observed in five cases of albuminuria 
with granular casts, all of which cases, I believe, were of car- 
diac lesion in the opinion of the attending physician, or, at 
any rate, those in which cardiac trouble was evident. I have 
noticed the oxychloride color twelve times in all, always in 
cases soon terminating fatally. 

SUMMARY NO. 3. 

Fatal cases of albuminuria, with also presence of 
granular, fatty or waxy casts. 

I. Urea estimations in 28 fatal cases showed average 24 hours' 
quantity of urea to He 14 grammes (210 grains). 

* Medical Current, p. ir, 1895. 



618 CLINICAL MEMORANDA AND SUMMARY. 

II. Urea estimations in 210 other cases, non-albuminuric, with- 
out casts, and non-diabetic, showed average quantity of urea 
to be 23 grammes (350 grains). 

III. Percentage quantity of albumin in 49 fatal cases: 

Up to or above the first mark, 1, on Esbach tube, . . . 21 

Less than up to the mark, 1, on Esbach tube, 12 

Quantity too small to be measured at all, but plain trace 
with Ultzmann's test, .16 

IV. Specific gravity in 44 fatal cases: 

1,015 or less, 21 cases. 

Abo^e 1,015, 23 cases. 

Above 1,020, 9 cases. 

Above 1,030, . . . 3 cases. 

V. Twenty-four hours' quantity of urine in 28 fatal cases: 

Above 3 pints ( 1,500 c.c), 8 cases. 

Below 3 pints (1,500 c.c), 20 cases. 

Below 2 pints (1,000 c.c), 17 cases. 

Below 1 pint (500 c.c ), 5 cases. 

VI. Color and appearance in 5 fatal cases was observed to be that 
imitated by diluting oxy chloride of iron solution with equal 
parts of water. 



MISCELLANEOUS QUESTIONS ON THE CASES OF ALBUMI- 
NURIA WITH GRANULAR, FATTY OR WAXY CASTS. 

i. Was urea always much diminished when albumin and 
casts were abundant ? 

Answer. — No. In case No. 81. in which the most albumin 
of any was found, e. g., up to the seventh mark on the Es- 
bach tube, and in which numerous casts of various kinds, 
granular, fatty and waxy, were found, three hundred grains of 
urea (nearly 20 grammes) were voided in forty-two ounces 
(1,260 c.c.) of urine. The patient died o # f suffocation from 
dropsy, without at any time showing uraemic symptoms. The 
analysis above mentioned was made a few weeks before death. 

2. Was urea usually decreased, either in grains per ounce 
or grains per twenty-four hours, in those cases in which per- 
centage of albumin was high ? 

Answer. — Yes, in fourteen out of eighteen such cases. 

3. Was urea ever excessive in quantity in any of these 
cases with high percentage of albumin ? 



MORTALITY IN 500 CASES OF ALBUMINURIA. 619 

Answer. — Never in total quantity per twenty-four hours. 
In grains per ounce (grammes per liter) it was from normal to 
excessive several times — -three times I found it seven or eight 
grains per fluid ounce (15-17 grammes per liter); once twelve 
grains per ounce (25 grammes per liter); once sixteen grains 
per ounce (34 grammes per liter) a few days before death. I 
have seen it eight to twelve grains per ounce (17-25 grammes 
per liter) twenty-four hours before death. In Case 79 a 
woman who passed but one fluidounce of urine in twenty- 
four hours (40 c.c), I found the urea twenty-three grains per 
fluidounce (49 grammes per liter). She died a few days 
afterwards. 

4. How low relatively, that is, in grains per ounce, was 
urea observed in cases where there was high percentage of 
albumin ? 

Answer. — In eighteen cases in which the percentage of al- 
bumin was high, urea occurred as low as one grain per fluid- 
ounce (2 grammes per liter) once ; two to two and a half 
grains per ounce several times ; four or five grains per ounce 
several times. 

5. In how many of the fatal cases was cedema or dropsy 
observed ? 

Answer. — In fourteen. 

6. In how many dyspnoea ? 
Answer. — In eight, so far as I know. 

7. In how many were cardiac lesions plainly evident ? 
Answer. — In nine ; hypertrophy, four ; dilatation, three ; 

valvular diseases, three ; all three, one. 

8. In how many nausea or vomiting ? 
Answer. — Five. 

9. In how many retinal troubles ? 
A nswer. — Four. 

10. Were there any cases in which no symptoms were 
noticed other than the condition of the urine ? 

Answer.Ycs y several. Case 52, an elderly man was pro- 



620 CLINICAL MEMORANDA AND SUMMARY. 

nounced, ten days before death, to be without organic disease 
of any kind by one of the best experts in physical diagnosis 
whom I know of in the United States. The urine, however, 
told the story : Albumin plainly present in small quantity, 
hyaline casts for a week or two, followed by sudden appari- 
tion of numerous granular casts, and then death from uraemia 
in three or four days. 

Case 28 was an old gentleman without any symptoms at all 
which I can recall or have record of. I made several exam- 
inations of the twenty-four hours' urine. It averaged thirty- 
two fluidounces (960 c.c); night urine exceeded day, specific 
gravity was 1,018, urea 200 grains (13 grammes) in twenty- 
four hours. Trace of albumin and a few granular and fatty 
casts. He died suddenly, when apparently better than when 
I saw him last. 

Case 33 was another elderly man, whose only symptom was 
nausea. This grew worse and worse until finally he could 
retain nothing on his stomach. His urine then was as fol- 
lows: Thirty fluid ounces (900 c.c.) in twenty-four hours, 
night volume equal to that of day ; specific gravity 1,012, al- 
bumin about one-sixtieth, urea 170 grains (11 grammes) per 
twenty-four hours, dark granular casts in sediment. Death 
in a week. 

11. What are apparently the most unfavorable signs shown 
by the urine ? 

Answers. — (1) The oxychloride color thus far an invariably 
fatal sign ; no recoveries. (2) The long, dark, straight, gran- 
ular casts ; recovery in only one case thus far noted, and that 
not yet assured, in a boy of ten. (3) The granular casts, 
which, with a low power, seem to be of a mouse color, but 
with higher powers are seen to be fatty. I cannot give exact 
figures in regard to these last, but do not recall any recoveries 
at present, and can remember several deaths. (Reprinted 
from the writer's paper in the N. Y. Med. Times, 1895.) 



DIAGNOSTIC SUMMARY OF URINARY DISEASES. 621 



DIAGNOSTIC SUMMARY OF URINARY DISEASES. 

The following summary may be found useful for diagnostic 
purposes : 

Movable Kidney. — The patient is commonly a woman, 
either a young woman of chlorotic type or a thin woman be- 
tween twenty and forty, who has borne several children, per- 
haps in rapid succession. She may have a bewildering corn- 
plexus of symptoms, mental, neurasthenic, gastro-intestinal, 
hepatic, uterine, ovarian, as well as renal. She suffers from 
renal pain, which may be either a dull, aching, dragging pain 
in the side, with severe attacks like renal colic (Dietl's crises), 
or be chronic like a neuralgia, with severe exacerbations. 
She has a movable tumor in the loin, manipulation of which 
may cause peculiar sinking, fainting sensation, or nausea. 
She may have frequency of urination and vesical tenesmus, 
but the urine may not show abnormal features except when 
blood is present or nephritis or tuberculosis co-exist. At 
times the urine is scanty and high-colored, or may be sup- 
pressed for a short time, following which the patient will pass 
urine abundantly for a short period. 

Renal Embolism. — The patient has usually a history of en- 
docarditis, suddenly feels a pain in the region of the kidneys, 
and has repeated chills and various cardiac symptoms ; the 
renal pain may be severe enough to cause vomiting and col- 
lapse. The urine becomes suddenly albuminous, but the al- 
bumin disappears in from two to four weeks ; tube-casts are 
found (hyaline, epithelial and leukocyte) for a few days, but 
soon disappear. Evidences of the disease may pass away in 
a few weeks. 

Active Renal Hyperemia. — The patient has a history of a 
surgical operation on the urinary tract, or of exposure to cold, 
or of some acute inflammatory disease. The condition is also 
present in cases of poisoning, as by Cantharides and Turpen- 



622 CLINICAL MEMORANDA AND SUMMARY. 

tine. There is frequency of urination, urgency and possibly 
straining, but the urine is scanty, there is pain in the back, 
sometimes headache, nausea and vomiting. If the condition 
is not relieved, the patient may show alarming symptoms — 
delirium, coma or convulsions. The urine is decreased or 
suppressed ; does not always contain albumin or casts, but 
quite commonly a sediment of urates associated with high 
color and high specific gravity, and sometimes more or less 
blood. Mild cases are found in many patients suffering from 
la grippe. The course is usually short and the termination 
favorable with proper management, but fatal cases after sur- 
gical operations or even the passage of a sound occasionally 
occur. 

Passive Renal Hyperaemia. — The patient has a history of 
some obstruction to the circulation, commonly valvular dis- 
ease of the heart. He complains of difficulty of breathing, 
especially on exertion, becomes ©edematous first about the 
feet or ankles, finally generally dropsical, but not usually 
about the face. Percussion sometimes shows presence of hy- 
drothorax, usually most noticeable on the right side. The 
pulse is weak and rapid, and the patient may have a hacking 
cough. The urine is diminished in quantity sometimes to 
even less than ten fluidounces per twenty-four hours, is of 
high specific gravity, 1025 or upward, of deep red color and 
often cloudy from urates. The urine contains a small or 
moderate quantity of albumin and a few casts, seldom fatty 
or waxy. The course of the disease is usually slow and de- 
pends on the relief which can be given to the heart. 

Acute Nephritis. — The patient is a child or young person 
with history of recent acute infectious disease, or a person 
with septic or toxic history, or that of exposure to cold and 
wet ; sometimes a child with recent history of gastro-intestinal 
disorder only, such as vomiting or pain in the stomach and 
bowels. His face is (Edematous, especially above the eyes, 
and he becomes more or less generally dropsical ; he is pallid, 



DIAGNOSTIC SUMMARY OF URINARY DISEASES. 623 

weak, drowsy, and may have convulsions. The urine either 
gradually or suddenly diminishes in quantity, is " smoky " in 
hue from the presence of blood, abundantly albuminous and 
contains numerous casts, at first hyaline, epithelial and blood, 
later granular, later fatty and waxy. The urine may decrease 
to less than ten ounces per twenty-four hours, or become en- 
tirely suppressed. Cases without history of infectious diseases 
may show less blood or but little blood in the urine. The 
disease lasts about four weeks and two out of three recover 
in post-scarlatinal cases. 

In other cases the prognosis is usually more favorable. 

Acute Nephritis of Pregnancy. — The patient is a woman 
who has been pregnant three months or more and is most 
likely a primipara, or one with history of convulsions during 
previous gestation or of neurotic family history. Her general 
condition may be unimpaired for weeks or months, but in the 
later months of gestation she is dropsical not only about the 
feet, but also in the face and elsewhere ; she loses her appetite 
and has nausea and vomiting any time during the day ; her 
pulse is that of high tension, slow, full, and incompressible ; 
she has headache, which may be severe, visual disturbances 
(dimness or haziness of vision or complete loss of sight) and 
epigastric distress, at times severe burning pain. The urine 
gradually diminishes in quantity, but is liable any time 
to a sudden decrease in quantity and to a considerable in- 
crease in urea in grains per fluidounce (12 to 17), at which 
time it becomes highly albuminous, but contains very few 
casts and seldom blood. Soon following the sudden decrease 
in urine she may have convulsions and, if the convulsive seiz- 
ures are repeated several times, she becomes comatose and 
dies, or she may die during the convulsions. In some cases 
there are practically no noteworthy symptoms other than 
malaise and slight headache, until the sudden decrease in the 
quantity of urine and the presence of a large amount of al- 
bumin in it ushers in convulsions. If recovery is to take 



624 CLINICAL MEMORANDA AND SUMMARY. 

place the symptoms subside after delivery. Convulsions oc- 
curring after delivery are usually an unfavorable sign. Pa- 
tients who recover may have a small amount of albumin in 
the urine for years afterward before it finally disappears. 

Chronic Diffuse Nephritis Without Induration — (Large 
white or mottled kidney). — The patient is usually between 
twenty and forty years of age, with a history of either anaemia, 
alcoholism or severe privations ; it occurs, however, in young 
women, children and others without known cause, unless it 
be due to anaemia. The clinical features are pallor, puffiness 
under the eyes, doughy face, difficulty of breathing, an- 
orexia and vomiting (especially in the early morning), weak- 
ness and dropsy. Severe digestive disturbances are not in- 
variably present. The urine varies in quantity, but is not 
high in specific gravity nor usually high in color. The night 
urine equals or exceeds the day urine in quantity. A large 
amount of albumin is present, and numerous large casts, hya- 
line, granular, fatty and waxy. The sediment is likely to be 
whitish in color with, perhaps, reddish uric acid crystals and 
microscopically contains a large number of different objects. 

The patient, if likely to recover, will do so in about a year. 
The longer the disease lasts the less likely is recovery. 

Treatment. — Milk diet for at least three weeks, and non- 
nitrogenous diet subsequently, together with Apocynum, Fer- 
rum and Arsenicum, are the chief reliance in treatment. 

Secondary Chronic Interstitial Nephritis. — The patient has 
a history of large mottled or large white kidney persisting for 
a year or more, until circulatory and cardiac symptoms are 
prominent (increase of pulse tension, accentuation of the sec- 
ond sound of the heart, hypertrophy and eventually dilatation 
of the heart). He has dyspnoea of an asthmatic character 
from uraemia, and pulmonary oedema or hydrothorax. Before 
cardiac dilatation he voids urine more abundantly than ever, 
pale in color, of low specific gravity, deficient in urea, but 
containing an abundance of albumin and numerous casts, in- 



DIAGNOSTIC SUMMARY OF URINARY DISEASES. 625 

eluding waxy. Ursemic symptoms are present. He may have 
headache, dysentery, delirium, coma, convulsions or paralysis. 
He dies from collapse of the heart, secondary inflammations, 
general oedema with exhaustion, or uraemia as above. The 
patient may live several years, but will, in all probability, 
succumb eventually. 

For treatment see general subject in preceding pages. 

Primary Chronic Interstitial Nephritis (Contracting Kid- 
ney). — Diagnostic hint. — The disease is an obscure one. As 
a rule, albuminuria coinciding with headache, dyspepsia and 
a tense pulse signifies contracting kidney. There are, how- 
ever, several kinds of cases : 

i. Mild, Slow Cases.— The patient is a man over forty 
years of age, with a history of previous good health, prosper- 
ity, sedentary habits, and addiction to hearty eating. He is 
unaware that anything is the matter with him until he is 
either rejected for life insurance or happens to notice that he 
is rising more frequently at night to urinate than in former 
years. Physical examination may discover slight accentua- 
tion of the second sound of the heart, arterio-sclerosis or myo- 
carditis, but the patient may not show well-marked evidences 
of cardiac disease at first, and may be mentally and physi ly 
active without ill results. He voids, however, pale urine co- 
piously during the night, and the day urine, which is seldom 
of normal specific gravity, contains at least a trace of albumin 
and a few hyaline casts. The total quantity of phosphoric 
acid is usually subnormal. The patient may continue about 
his duties for years without showing marked symptoms of any 
kind, except more or less muscular weakness, but is liable to 
sudden death from acute uraemia, as the case becomes more 
pronounced, which it may do suddenly after years of quies- 
cence. 

2. Typical Cases of more or less severity. — The patient has 
a history as above, but in addition may be gouty, or of gouty 
or apoplectic ancestry, or have a history of stricture or ob- 
40 



626 CLINICAL MEMORANDA AND SUMMARY. 

struction to the free flow of urine. He complains of weak- 
ness, headache, digestive disturbances, intractable rheumatic 
pains and persistent neuralgia, especially post-cervical. (He 
may not, however, manifest all these symptoms in earlier 
stages, but is likely to suffer from at least two or more of 
them.) He will show, moreover, some of the following evi- 
dences sooner or later : Vertigo, insomnia, shortness of breath 
and asthmatic attacks, angina, haemorrhages (nasal, cerebral, 
retinal or cutaneous), transitory blindness, ringing or throb- 
bing in the ears, mental disturbance ; or peculiar temperature 
variations with weakness, pallor, loss of weight and night- 
sweats. He voids, as a rule, more urine than normal, of less- 
ened specific gravity, containing, in the daytime or after exer- 
cise, at least a trace of albumin or a few casts. The night 
urine is pale and may contain neither albumin nor casts. 

Physical examination may show arterio-sclerosis, which 
may be marked in the temporals, and accentuation of the sec- 
ond sound of the heart ; also sometimes a slow, hard, cord-like 
radial pulse, and displacement of the apex-beat. 

3. Cases with Severe Exacerbations. — The patient, origi- 
nally with or without marked evidences of the disease, may 
be seized with an agonizing headache, followed by convul- 
sions and coma, with highly albuminous urine. If he recover, 
albumin in the urine may diminish to a trace. Retinitis, ap- 
oplexy, paralysis, delirium or insanity may become features of 
his case. He may have convulsions, recover, and apparently 
be doing well, but suddenly grow weak and die of exhaustion. 
Or he may have dropsy for a time and recover from it in 
great part, but succumb to later attacks. 

4. Cases in the Stage of Cardiac Dilatation. — The patient 
is elderly and has a history of contracting kidney of many 
years' standing, or perhaps of enlarged prostate. He has ex- 
treme difficulty of breathing, is dropsical and feeble ; his 
pulse is weak and rapid; there are pulsations in the jugulars; 
he has a dilated heart and cirrhosis of the liver. There is a 



DIAGNOSTIC SUMMARY OF URINARY DISEASES. 627 

strong odor of the urine in his breath and to his body, and 
his perspiration is sticky and urinous. His face is sunken 
and his features drawn and haggard. He is at first wakeful 
and anxious, but later becomes semi-delirious, drowsy and 
finally comatose. 

Amyloid Kidney. — The patient may be either a child, or is 
more commonly between twenty and fifty years of age. He 
is sometimes of tuberculous ancestry, and has a history of 
syphilis, chronic suppuration, malignant growth, or some ob- 
scure cachexia. He is likely to be pale, sallow, cachectic, of 
muddy complexion, with brown rings round the eyelids, and 
manifests gastro-intestinal symptoms often in the form of an 
obstinate diarrhoea. He may have an enlarged liver and 
spleen, and he becomes dropsical and weak. He voids ex- 
ceedingly clear urine, which is abundant in quantity and usu- 
ally highly albuminous. The sediment is very scanty, but 
shows large, broad, hyaline and waxy casts, occasionally also 
granular and fatty. The disease is said to be the result of 
the long-continued action of toxins produced by the staphy. 
lococcus aureus, and recovery is unlikely. 

Cystic Kidney. — The patient is usually between forty and 
and fifty-five years of age, with history and symptoms of con- 
tracting kidney, together with obstinate hsematuria and a bi- 
lateral, soft, non-fluctuant, kidney-shaped renal tumor, which, 
in the later stages, bulges out the abdomen sufficiently to be 
recognized by inspection. The urine is that of contracting 
kidney, together with blood (which, in later stages, is enor- 
mous in quantity), large granular casts, and finally triple- 
phosphate crystals due to accompanying cystitis. The patient 
may live a number of years, bat eventually dies of uraemia or 
exhaustion from severe haemorrhages. 

Paranephric Abscess. — Diagnostic hint: — A painful tumor 
in the region of the kidneys, together with fever, points to 
paranephric abscess. 

The patient is most likely an adult male, with history of a 



628 CLINICAL MEMORANDA AND SUMMARY. 

wound, surgical operation, or some suppurative lesion ; if a 
woman, she has probably had pelvic cellulitis. In either sex 
it may follow appendicular abscess. 

The patient has fever and the various disturbances of the 
febrile state, pain in the region of the kidneys, worse on pres- 
sure and on movement, and finally a swelling occupying the 
lumbar region and sufficiently large to cause bulging, while 
the skin over it is congested and ©edematous. The urine may 
not be noticeably abnormal unless the abscess ruptures into 
the urinary tract, when large quantities of pus and free fat 
will suddenly appear. 

The course may be rapid, and, unless the pus can be evacu- 
ated, death may take place from septicaemia or other means. 
Early surgical treatment, with drainage in primary and recent 
cases, may effect a cure. Cases secondary to grave lesions of 
the kidneys or neighboring organs are usually fatal, and espe- 
cially when the disease follows the puerperal state in septic 
conditions. 

Acute Suppurative Nephritis (Renal Abscess). — Diagnostic 
hint: — Pus in the urine with grave constitutional disturbance 
suggests suppurative nephritis. 

The patient is usually an elderly male, with a history of 
enlarged prostate and cystitis, less commonly either male or 
female, who, at any age, has a history of injury of the kidney, 
surgical operation on the lower urinary tract, urethral strict- 
ure, or embolism (as from malignant endocarditis), or preg- 
nancy. He has chills, fever, sweat and sometimes pains in 
the region of the kidneys, together with various nervous, 
digestive and circulatory symptoms, as in fevers. His face is 
at first flushed, later sallow or jaundiced ; the expression is 
anxious ; the mouth dry and the tongue coated, often brown, 
fissured and crusted ; the pulse is rapid and feeble. He soon 
becomes drowsy, more or less delirious, goes into profound 
coma and then dies, usually in a few days after the onset of 
the disease. 



DIAGNOSTIC SUMMARY OF URINARY DISEASES. 629 

The urine is usually alkaline, offensive, contains pus and 
abundance of albumin, triple-phosphate crystals and swarms 
of micro-organisms. Casts may be absent ; if present, they 
are dark granular or composed of cocci. Micturition is fre- 
quent, but the quantity voided is small. 

Treatment. — The diet is to be sustaining and to include 
stimulants. The treatment to disinfect the urinary tract, 
Urotropin or Helmitol being the principal drugs : 

Suppurative Nephritis (Chronic Cases). — Diagnostic hint: 
— Progressive loss of flesh and strength in cases not tubercu- 
lous, accompanied by pyuria, suggests chronic suppurative 
nephritis. 

There is loss of flesh and strength, with nervous, digestive 
and circulatory symptoms irregularly, and in less degree than 
in the more acute cases. The urine is like that of contracting 
kidney, together with pyuria. The patient may suffer for 
months or possibly a year or two, or the kidney originally af- 
fected may undergo atrophy, and recovery for the time take 
place. 

Pyelitis. — Diagnostic hint : — Pus, without casts, in acid 
urine, without the clinical features of cystitis or urethritis, 
points to pyelitis. 

The patient has most commonly a history of renal calculus, 
tuberculosis, gonorrhoea, or other infection of the lower uri- 
uary tract, as from use of unclean instruments, or failure to 
avoid sepsis after operations. In general, he has a history of 
irritation of the pelvis of the kidney from bacterial or toxic 
causes, presence of a foreign body, or rupture of a neighboring 
abscess.. 

In women there may be history of pregnancy or recent de- 
livery. The patient may present (a) few evidences of any 
trouble and few or no constitutional symptoms, or complain 
of (b) dull pain in the region of one or both kidneys, with 
sensitiveness on pressure over one or the other kidney, or pos- 
sibly both kidneys. During attacks of pain he may have 



630 CLINICAL MEMORANDA AND SUMMARY. 

fever at night. The urine may be acid in reaction, if the case 
is uncomplicated with cystitis. In such cases it contains 
merely pus and a little albumin, usually less than ten per 
cent, bulk measurement by centrifugal sedimentation. The 
urine varies in character according to cause and complica- 
tions. (See "Renal Calculus" and "Tuberculosis"). 

In long-standing cases of chronic pyelitis there is polyuria 
and light greenish urine, acid when voided, but soon turning 
alkaline. The microscope shows incomplete crystals of triple- 
phosphate in the freshly- voided urine. There is frequent but 
painless micturition. 

The course of the disease depends upon the cause ; after in- 
fectious diseases recovery usually takes place, and also wheu 
due to calculus in an operable case, after calculus is removed. 
Otherwise the case is a serious one and recovery unlikely, 
though the patient may live some years. 

Renal Calculus. — Diagnostic hint : — Blood in the urine, 
more abundant after exercise, together with pain in the loin, 
points to renal calculus. 

The patient is commonly a child or a middle-aged adult of 
sedentary or luxurious habits, with a history of residence in a 
limestone district, especially where artesian well-water is 
drunk, and often with recent history of a violent sudden exer- 
tion, jolt or fall. He is usually in good general condition and 
free from constitutional symptoms, but complains of more or 
less constant dull pain in the loin, especially when riding 
over a rough road, and may flinch when pressure is applied to 
the region of one or the other kidney, but cases occur in 
which no sensitiveness to pressure exists. Before renal colic 
occurs, the diagnosis may be verified by the X-ray apparatus. 

Sooner or later he may suffer from an acute attack of pain 
(renal colic), especially after violent sudden exertion, jolt or 
fall, though it may occur in the night, waking the patient 
from sleep. Renal colic begins suddenly, is cutting, stabbing, 
sharply-defined, follows the course of the ureter toward the 



DIAGNOSTIC SUMMARY OF URINARY DISEASES. 631 

genitals or into the thigh. The patient is in agony, lies usu- 
ally on affected side with updrawn knees ; the testicle on the 
affected side is frequently retracted ; there may be chills or 
chilliness, faintness, nausea and vomiting. The pain may be 
most severe in the back or radiate upward into the epigas- 
trium. After an hour or so it may cease as suddenly as it 
came on, or recurrent paroxysms may last for hours. The 
urine voided before renal colic may be almost normal during 
the night, but in the daytime or after exercise will contain 
either blood, pus, or both, and sometimes crystals, especially 
sharp-pointed crystals of uric acid. Cases have occurred in 
which the writer has never found crystals, but either blood or 
pus were present in the day urine, and sometimes also in the 
night. 

Hyaline, epithelial, and yellow granular casts are usually 
found in the day urine in cases where they are not hidden by 
blood or pus During renal colic micturition is frequent, but 
the urine is scanty or may be suppressed. The ratio of urea 
to uric acid may be low, below thirty to one. The amount of 
albumin is slight, corresponding to the blood and pus pres- 
ent. The reaction of the urine is usually acid, except in 
cases of phosphatic calculi, when it is alkaline. 

Hydronephrosis. — Diagnostic hint : — A tumor in the loin, 
whose size varies with the amount of urine, points to hydro- 
nephrosis or pyonephrosis. 

The patient has a history of long-continued obstruction to 
the free flow of urine, as from stricture of the urethra, en- 
larged prostate, twists, or spasmodic contraction of the ureters ; 
tumors, calculi, displacements of the uterus and movable kid- 
ney are common causes. The patient may present (a) no 
symptoms which are characteristic, especially in the case of 
women ; or may have (b) constant dull pain in the loin over 
the affected kidney, with gradual development of eventually 
large tumor, unilateral or bilateral, filling the greater part of 
abdomen, and finally the symptoms of pyonephrosis and sup- 



632 CLINICAL MEMORANDA AND SUMMARY. 

purative nephritis or contracting kidney and chronic uraemia, 
or (c) intermittent cases may occur in which the tumor in- 
creases in size as the urine diminishes in quantity, and the 
patient has vomiting and fever for a few days, followed by 
polyuria, possibly hsematuria, diminution in the volume of 
the tumor, and relief. The urine may be (a) almost normal, 
or (b) present' the features of the disease causing the hydrone- 
phrosis, as renal calculus or enlarged prostate, or (c), in late 
stages, the features of contracting kidney. The fluid aspi- 
rated from the tumor is neutral or acid in reaction, never al- 
kaline when fresh. 

Pyonephrosis. — The patient has a history like that of hy- 
dronephrosis and of pyelitis. Commonly he has stone im- 
pacted in the pelvis of the kidney. The tumor is not so large 
as in hydronephrosis, and aspiration shows pus. The patient 
has the symptoms of pyelitis and the urine the features of this 
disease, especially those of calculous pyelitis, increasing as the 
tumor diminishes in size. Large amounts of free fat are 
sometimes found in the urine 

Renal Tuberculosis. — Diagnostic hint : — Hsematuria at 
night in a person under forty, with pyrexia more or less 
marked, points to renal tuberculosis, especially if vesical 
symptoms are absent. 

The patient is usually a male from twenty to thirty years 
of age, light in weight, often puny, anaemic, pale, with cold 
hands and clubbed finger-nails. He has a family history of 
cancer and tuberculosis, and may have suffered from repeated 
renal congestions The finger in the rectum may discover 
nodules in the prostate and seminal vesicles. He has in- 
creased frequency of urination, both during the day and the 
night, and may pass blood during the night. The urine may 
first contain a little albumin only, later blood, pus and tuber- 
cular debris, with few or no tube-casts. Pain, painful urina- 
tion, swelling in the loin and the general symptoms of chronic 
tuberculosis are finally present. Renal calculus may form in 
the course of the disease. 



DIAGNOSTIC SUMMARY OF URINARY DISEASES. 633 

Malignant Renal Tumors. — Diagnostic bint: — Unaccount- 
able, persistent, violent pain in the region of the kidneys, to- 
gether with progressive cachexia, should suggest the presence 
of malignant disease. 

If the tumor is primary, the patient is more commonly a 
male in early or late adult life ; occasionally an infant. If 
secondary, he has a history of primary malignant disease of 
the testicles or in the vicinity of the kidneys, especially of the 
right kidney. He has pain, not affected by movement, a feel- 
ing of pressure, becomes emaciated and cachectic, passes 
bloody urine and shows evidences of an immovable tumor in 
the lumbar region, the shape of the kidney, on one or both 
sides. As a result of the pressure of the tumor he may have 
oedema or ascites, or vomiting, constipation, anorexia, and 
icterus, or extreme pain in the chest, back, hip, thigh, tes- 
ticles and leg. The urine, sooner or later, contains blood, 
which is usually small in amount at first, bears no relation to 
movement, and eventually becomes large in amount. Large 
shreds of connective tissue may be found by centrifugal sedi- 
mentation of the urine well shaken and diluted with four or 
five times its volume of water. Pns and debris are not con- 
spicuous features. Nephritic complications cause presence of 
casts, uric acid crystals and more albumin than the blood ac- 
counts for. 

Ureteritis. — Diagnostic hint : — An urgent desire to urinate 
followed by cramping pain ascending to the kidney suggests 
spasm of the ureter. 

The patient has a history of pyelitis, cystitis, urethritis, or 
other disease of the lower urinary tract, and is quite com- 
monly a woman. She presents either (a) the features of py- 
elitis, or has (b) pain along the course of the ureters, and 
shows evidences of tenderness when pressure is made on the 
vesical end of the ureter by means of the finger in the vagina. 
She may wake in the night with a pressing desire to urinate ; 
urination is accompanied by more or less pain and spasm, and 



634 CLINICAL MEMORANDA AND SUMMARY. 

may be followed by a cramping pain ascending to the kidney. 
The patient sleeps on the affected side and may have the 
habit of drawing the opposite thigh up over its fellow against 
the abdomen. She is unable to endure sexual intercourse, 
and after an attack of pain is excited and hysterical. Injec- 
tion of warm water into the bladder causes an irresistible de- 
sire to urinate, which, if not promptly attended to, is followed 
by the cramping pain (renal tenesmus). In severe cases pres- 
sure or injection as above may bring on the spasm, and sur- 
gical intervention may be a necessity. The urine may show 
the features of pyelitis. 

Cystitis. — Diagnostic hint: — Cloudy urine voided fre- 
quently, with pain and straining, points to cystitis. 

The patient is either a young man who has had gonorrhoea, 
a middle-aged or old man with stone in the bladder, an elderly 
man with enlarged prostate and retention of urine, or a woman 
with vaginal, urethral or rectal disease, or who has recently 
borne a child. Cystitis from diseases of the spinal cord, re- 
sulting in retention, is also common, especially in locomotor 
ataxia. The patient has more or less pain in the bladder, fre- 
quency of urination, more or less straining after urinating, 
more or less difficulty in urinating, and, after a time, back- 
ache in the sacral region, leg-ache, headache and irregular 
movements of the bowels. The facial expression is one of 
weariness and depression, and in severe cases the features, 
after a time, are haggard and drawn. The digestion becomes 
impaired and there is more or less loss of flesh and strength. 
In acute cases there is slight febrile disturbance, considerable 
pain and tenesmus. The patient voids cloudy urine of acid 
reaction containing flocculent pus, blood-corpuscles and innu- 
merable bacteria. In chronic cases the patient suffers less 
from pain and straining, and voids cloudy, offensive, alkaline 
urine, with sticky pus and triple phosphate. In acute cases 
albumin is sometimes quite abundant ; in chronic cases 
merely a trace. The patient may recover from an acute at- 



DIAGNOSTIC SUMMARY OF URINARY DISEASES. 635 

tack in from a week or two to a month, according to circum- 
stances. Chronic cases may continue indefinitely, and ter- 
minate in suppurative nephritis and death, unless the cause 
can be relieved by surgical, measures. Cystitis is essentially a 
secondary disorder. 

Abscess of the Bladder. — The patient has the history and 
features of cystitis, but also localized induration, pain and 
tenderness shown by finger in the rectum. Sloughs of 
mucous membrane may plug the urethra. 

Prevesical Inflammation. — This condition is shown by a 
sharply-defined, usually symmetrical tumor, just above the 
symphysis, sometimes terminating in suppuration. 

Stone in the Bladder. — Diagnostic hint : — Frequency of ur- 
ination, with pain and sudden stoppage of the stream, points 
to vesical calculus. 

The patient is more commonly a male, who lives in a lime- 
stone district, and especially one who from any cause has 
residual urine, or who has had renal colic, but children may 
have uric acid calculi without residual urine. Female chil- 
dren may occasionally develop stone in the bladder as a result 
of the introduction of foreign bodies into the bladder from 
without, as, for example, hair-pins. The patient, if a male 
child, habitually pulls at the prepuce, or, if an adult, squeezes 
and rubs the under surface of the glans. He is likely to lie 
upon his back with hips raised to relieve the pain, which is 
felt along the urethra, at the end of the penis, in the testicles, 
or down the thighs. When urinating, which is done fre- 
quently, he feels the pain, and a sudden stoppage of the 
stream may occur, with a twinge of sharp pain shooting to 
the meatus. The urine presents the features of a gradually 
increasing cystitis, with deposit of blood and large numbers 
of crystals. In severe cases the urine is very foul and the pus 
is mixed with blood. The patient is worse when on his feet, 
and can ride with more ease than he can walk. 

Tuberculosis of the Bladder. — Diagnostic hint: — Symptoms 



636 CLINICAL MEMORANDA AND SUMMARY. 

like those of vesical calculus in a tuberculous patient should 
suggest vesical tuberculosis. 

The patient is usually between fifteen and twenty-five years 
of age, with family history of tuberculosis or cancer, and per- 
sonal history of masturbation with increasing frequency of ur- 
ination. Cases of renal tuberculosis may develop tuberculosis 
of the bladder, in which the features are much the same as 
those of vesical stone, but the stoppage of the stream relieves 
the pain, which is in the middle of the penis and does not 
pass forward into the glans. The bladder is contracted and 
unable to hold more than five or six ounces ; the pain ceases 
when half of this is voided ; the day and night frequency is 
about the same, or the night frequency may rapidly increase. 
Bacteriological examination of the sediment may show the 
presence of Bacillus tuberculosis. 

A frequent course pursued by tuberculosis is — first, devel- 
opment in one kidney ; second, in the bladder ; third, in the 
other kidney. The bladder may be infected, however, from 
the seminal vesicles or prostate. 

Tumors of the Bladder. — Diagnostic hint: — Intermittent 
haematuria and pain in the bladder should suggest presence of 
a vesical tumor. 

The patient is more commonly a middle-aged male, espe- 
cially in cases other than myxoma, which occurs more often 
in children. 

i. Benign Growths. — The patient first has hematuria, then 
pain and frequency, then relief of the pain after an attack of 
bleeding. He is likely to pass blood during the night, and 
his pain bears no relation to exercise. Hsematuria is inter- 
mittent, with progressively increasing frequency. 

2. Malignant Growths. — The patient has pain and fre- 
quency before voiding blood ; he may cease to void blood, but 
yet suffer 'from pain and frequency. The writer has noticed 
in cancer of the bladder as much as twenty per cent, by bulk 
of albumin in urine free from blood (macroscopically) and 
without casts, but containing pus in moderate amount. 



DIAGNOSTIC SUMMARY OF URINARY DISEASES. 637 

The urine contains blood and large shreds of connective 
tissue. Enormous clots of blood may be passed, with great 
pain and straining, and so organized as to resist handling 
without disintegration. In malignant tumors large numbers 
of epithelia of a great variety of shapes, with large nuclei, are 
seen. In malignant cases the ringer in the rectum shows an 
area of induration in the bladder, and a sense of increased re- 
sistance when the bladder is empty ; the patient is over fifty 
years of age, and pain is a marked feature. 

In benign cases the patient may appear to recover after a 
haemorrhage, and attend to his duties as if he were nearly or 
quite well, but the tumor, if not removed, may in time press 
on the ureters, cause hydro- or pyonephrosis, and death from 
contracting kidney. The average duration of bladder growths 
unremoved is from three to seven years before death. 

Acute Prostatitis. — Diagnostic hint : — Feeling on the part 
of the patient of something protruding into the rectum, with 
constant painful urination, should suggest acute prostatitis. 

The patient is a man who has had gonorrhoea, especially if 
followed by stricture, or who has been addicted to sexual ex- 
cess. Less commonly the disease is due to irritation of the 
prostate from various other causes, as passage of instruments, 
use of strong injections, etc. 

He has a feeling of heat, weight and throbbing in the peri- 
neum, a constant desire to urinate without sense of relief, and 
great pain as the last few drops pass ; the prostate being 
greatly enlarged, even to the size of a small orange, he has a 
feeling of something protruding into his rectum, and makes 
ineffectual attempts at stool ; his mind is greatly disturbed 
and he may become slightly delirious or maniacal. There 
may be a slight febrile disturbance also. The finger in the 
rectum feels the enlarged prostate, which is exquisitely sensi- 
tive, and the touch of the finger excites immediate desire to 
urinate. After four to twelve days, if the temperature does 
not exceed ioi° F. at any time, and chills, sweat and prostra- 



638 CLINICAL MEMORANDA AND SUMMARY. 

tion are absent, resolution takes place and the patient recovers 
in about three weeks. Recovery is sometimes delayed until a 
stricture causing the disorder can be treated surgically. 

Prostatic Abscess. — The patient has a history of acute 
prostatitis, with marked chills, high fever and considerable 
diminution of perineal pain and tension, the pain being lan- 
cinating in character, but less tense. Bursting of the abscess 
causes all pain and discomfort to vanish, but, as a rule, surgi- 
cal intervention is necessary for relief. 

Chronic Prostatitis. — Diagnostic hint : — A history of acute 
prostatitis, followed by symptoms like those of vesical cal- 
culus, should suggest chronic prostatitis. 

The patient has usually a history of acute prostatitis, fol- 
lowing which the prostate remains slightly enlarged. If he 
has a slight muco-purulent oozing from the meatus and this 
history as above, the diagnosis is not difficult, but otherwise 
the features resemble stone in the bladder, and sounding may 
be necessary. The patient usually has great mental depres- 
sion, and an increase of pain on crossing the legs and in 
changing from sitting to standing, etc. The course is slow. 

Tuberculosis of the Prostate. — The patient is tubercular or 
debilitated, and grows very slowly, but steadily, worse. He 
has slight haemorrhages from the urethra without relief. The 
finger in the rectum feels a lumpy prostate, and the vasa 
deferentia, one or both, can be traced as infiltrated hard tubes. 
The ' bacillus tuberculosis may be found in the urine. The 
course is very slow and the prognosis unfavorable. 

Hypertrophy of the Prostate. — Diagnostic hint: — Fre- 
quency of urination at night in an elderly man points to pros- 
tatic hypertrophy. 

The patient is a man usually over fifty years of age, who 
first has difficulty in starting the flow of urine and voids urine 
too frequently at night, then has the features of cystitis to a 
greater or less degree. The finger in the rectum encounters 
a rounded, dense mass, either smooth and symmetrical or vari- 



DIAGNOSTIC SUMMARY OF URINARY DISEASES. 639 

ously distorted and nodulated. The urine at first is too abun- 
dant, pale, and of low specific gravity ; later, it presents the 
features of cystitis. 

The patient goes on a slow course of varying severity of 
symptoms, until finally retention of urine takes place as a re- 
sult of distortion of the prostatic urethra, with elevation of 
the level at the vesico-urethral orifice, and the use of the 
catheter is begun. After a varying length of time there is 
dilatation of the bladder, with hypertrophy ; the ureters are 
dilated, as also the pelvis of the kidney ; there is tendency to 
stone formation, to contracting kidney, and the patient either 
has suppurative nephritis and uraemia, or dies from uraemia 
without presenting the features of suppurative nephritis. 

Cancer of the Prostate. — The patient is usually an elderly 
man, with a history of injury or enlargement of the prostate, 
who has free haemorrhages from the urethra, with or without 
urination ; pain, peculiar hardness in the prostate, and possi- 
bly enlargement of the glands in the groin and pelvis. The 
patient may die without any ulceration or breaking-down of 
the tumor or rectal discharge, and the urine may show nothing 
abnormal save a little bladder mucus. 

In some cases connective-tissue shreds of considerable size 
are found in the urine. 

Diabetes Mellitus. — Diagnostic hint: — Polyuria, with urine 
of specific gravity above 1025, suggests diabetes mellitus. 

The patient, if under thirty, loses flesh, is hungry, thirsty 
and weak. The urine contains sugar and gives the red reac- 
tion with ferric chlorid. The patient is better at times, then 
worse again, and usually dies, within three years, of diabetic 
coma, preceded usually by gastric crises. The patient, if over 
thirty, and especially if over forty, may lose more or less flesh, 
but is likely to be corpulent, and his general condition may 
be fair for years. He is subject, however, to attacks when he 
feels weak, his mouth is dry and he voids a good deal of urine- 
He may be free from excessive hunger, thirst or loss of weight 



640 CLINICAL MEMORANDA AND SUMMARY. 

for years at a time. If he does not succumb to pneumonia or 
other complications, he may live fifteen or twenty years before 
the red reaction is obtained in the urine with ferric chlorid, 
after which he usually glows more or less rapidly worse, and 
dies of coma. 

Diabetes Insipidus. — The patient is likely to be under 
forty years of age. He is very thirsty and voids an enormous 
quantity of pale urine of low specific gravity. The patient is 
weak, easily chilled, has a capricious appetite, and complains 
of a sinking, gnawing sensation in the pit of the stomach. 

The disease may last the patient's life-time, but there is 
danger of development of tuberculosis, pneumonia, or organic 
brain lesion. Delicate children may die of exhaustion within 
a few years after the disease develops. 

PAIN AS A SYMPTOM OF URINARY DISEASES. 

The principal points in the significance of pain in urinary 
diseases are the following : 

i. Attacks of intense pain referred to the epigastrium, or to 
the umbilical region to the left of the median line, with slow, 
feeble pulse, much prostration and face bathed in perspira- 
tion, should suggest movable kidney. 

2. Chronic pain in the renal region, like a neuralgia, with 
restlessness, discomfort, general distress, loss of appetite, fre- 
quent and difficult urination, and not relieved by change of 
posture, also suggests movable kidney. 

3. Sudden pain in the back, with vomiting and chills, es- 
pecially if the heart is weak, suggests renal embolism. 

4. Deep-seated pain in the back over the kidneys, aching 
in the loins, either along the coarse of the ureters or radiating 
to the hips, with tenderness over the renal region on deep 
pressure, suggests acute renal hyperemia or acute nephritis ; 
also renal calculus. 

5. Headache, when obviously not due to other disorders, 



PAIN AS A SYMPTOM OF URINARY DISEASES. 641 

should always occasion the suspicion that some form of renal 
disease may be present, especially contracting kidney. 

6. Headache, with albuminuria, even if there are no other 
features, should suggest contracting kidney. 

7. Earache and noises in the ear are frequently observed in 
chronic nephritis. 

8. An acute, blinding headache, often agonizing, may pre- 
cede ursemic convulsions in contracting kidney. 

9. Headache and burning pain in the epigastrium in a 
pregnant woman suggest puerperal nephritis. 

10. Abdominal pain, with drowsiness, may indicate acute 
nephritis. 

11. A painful swelling in the region of the kidneys should 
suggest paranephric abscess. 

12. Severe paroxysmal pain in the region of one kidney, 
radiating from the flank into the bladder, suggests renal cal- 
culus, renal tenesmus and renal tuberculosis. 

13. Pain either fixed or shooting outward and downward 
from the kidneys, usually a dull or violent continuous aching, 
not affected by movement, suggests malignant tumor of the 
kidney. 

14. Dull pain in the region of one or both kidneys may be 
due to pyelitis or to oxaluria. 

15. A moderately severe pain, following course of one or 
both ureters, may indicate pyelitis and ureteritis. 

16. Similar pain with grave constitutional disturbance may 
be due to suppurative nephritis. 

17. Constant dull pain in the loin over one kidney or both, 
long-lasting and accompanied by fulness or tumor, suggests 
hydronephrosis or pyonephrosis. 

18. A dull ache, either fixed or radiating toward the geni- 
tals or upper portion of the thigh of affected side, may be due 
to stone in the kidney. 

19. Pain in the lower part of the leg, or in the heel, maybe 
due to stone in the kidney. 

4i 



642 CLINICAL MEMORANDA AND SUMMARY. 

20. A violent agonizing pain, beginning suddenly, espe- 
cially after exertion, shock or jolt, and cutting, stabbing, 
sharply defined along the course of the ureter, either toward 
the genitals or into the thigh (or radiating upwards into the 
epigastrium), and stopping as suddenly as it began, is renal 
colic, commonly due to calculus or tuberculosis. 

21. Slight pain in one kidney, or severe pain for a time, 
disappearing for years, or persisting as a constant dull pain in 
the loin, may be due to calculus in the substance of the kid- 
ney. 

22. Sudden violent renal pain occurring in paroxysms and 
not ceasing suddenly, but only gradually wearing off, suggests 
calculus impacted in the ureter. 

23. Severe abdominal pain, chiefly on one side, beginning 
in the renal region and gradually extending to the bladder, 
suggests acute ureteritis. 

24. A bearing-down pain in the renal region, increased by 
standing on the feet, suggests chronic ureteritis. 

25. A cramp-like pain felt after emptying the bladder, as- 
cending along course of ureter to the kidney, and also radiat- 
ing to the lower extremity of the affected side, points to spasm 
of the ureter (renal tenesmus). 

26. A distressing, persistent pain, referred to the region of 
the symphysis pubis and perhaps extending to the perinaeum 
and rectum, somewhat relieved by micturition and aggravated 
by constipation, is found in acute cystitis. 

27. Similar pain, but not so severe, together with backache 
in the sacral region, more or less headache and leg-ache, points 
to chronic cystitis. 

28. Pain along the urethra, at end of the penis, in the tes- 
ticles, and down the thighs, especially sharp when there is 
sudden stoppage of the stream of urine, and then felt most 
acutely at the meatus, points to stone in the bladder. 

29. Pain in the middle of the penis, relieved by sudden 
stoppage of the stream, points to vesical tuberculosis. 



THE METHYLENE-BLUE TEST. 643 

30. Pain in the bladder, followed by hsematuria and re- 
lieved by it, points to a benign bladder growth. Pain not 
relieved by intermittent haematuria, to a malignant growth. 

31. Severe pain, accompanying the passage of the last drops 
of urine, points to inflammation of the prostate or prostatic 
urethra, or to posterior urethritis. 

32. The above, with perineal pain and tension, especially 
points to acute prostatitis ; lancinating pain rather than tense, 
to prostatic abscess. 

^. Pain like that of vesical stone, 'with painful sensation 
when walking, an increase of it when crossing the legs, from 
sitting, or in changing posture from sitting to standing, may 
indicate chronic prostatitis. 

34. Dull pain and burning along the urethra frequently oc- 
curs in hypertrophy of the prostate . 

35. Pain during urination, either at the head of the penis 
or along the urethra, with extreme pain accompanying ejacu- 
lation during intercourse, points to seminal vesiculitis. 

THE METHYEENE-BLUE TEST. 

The method of performing this test has already been de- 
scribed in the chapter on Uremia. As to its clinical value, 
Achard and Castaigne write as follows : 

In interstitial nephritis there are evidences of impermeabil- 
ity, such as delayed appearance (frequently), and habitually 
prolonged elimination period. The authors have often made 
the diagnosis when other phenomena, such as albuminuria, 
were not in evidence. Considering the insidious nature of 
this disease, the test should be of great practical value. 

In acute and chronic diffuse nephritis it is quite different. 
Permeability appears to be retained for a long time. The 
same holds good for amyloid kidney. 

In functional albuminuria a slight prolongation of the 
period of elimination has been observed. 



644 CLINICAL MEMORANDA AND SUMMARY. 

In passive congestion of the kidneys from cardiac weakness 
the elimination of the bine does not appear to be interfered 
with. After the condition is of long standing, irregularities 
of elimination will appear. 

In diabetes elimination appears to be almost normal. If 
this disease coincides with actual organic disease of the kid- 
ney, impermeability is readily apparent. 

In urinary surgery operators have employed the blue in 
doubtful cases to determine whether or not the kidneys are 
sufficiently impaired to contraindicate operations on the uro- 
genital tract. The method has been combined with urethral 
catheterization, so that the permeability of each kidney may 
be ascertained. 

It was thought that the blue might prove of service in ob- 
stetrical practice, and foretell the possibility of eclampsia 
through evidences of renal inadequacy ; but these hopes have 
not been realized. An eclamptic may eliminate the blue nor- 
mally, while a case which eliminates badly will present no 
evidence of likelihood of eclampsia. 

UREMIA IN ITS CLINICAL BEARING. 

The reasons why a condition of chronic uraemia may be 
overlooked are as follows : 

1. On part of the patient assumption that nervousness or 
dyspepsia is the primary cause of his trouble, with result that 
he spends his time and money doctoring himself with adver- 
tised cures for these maladies. 

2. On part of the patient, ignorance or disregard of the fact 
that he is passing less urine than normal. Patients are very 
quick to notice that they are urinating more frequently than 
usual, or passing a larger amount of urine than usual, but few 
seem to notice when the urinary secretion is growing scanty, 
or to attach importance to a diminution in the quantity. 
Cases of contracting kidney are not infrequent in persons phy- 



THE METHYLENE-BLUE TEST. 645 

sically and mentally active, whose minds are occupied with 
affairs and who do not think of themselves until they are con- 
scious of unaccountable muscular weakness ; then, on investi- 
gation, it will be found perhaps that they are passing only fif- 
teen or twenty fluidounces of urine a day, in which the pres- 
ence of albumin and casts can readily be demonstrated, and 
in which urea is less than two hundred grains in amount. 

3. On part of the physician, disregard of the importance of 
examining urine voided during the day. If the patient is 
merely told to bring a sample of urine for examination, the 
chances are that he will bring the urine voided on rising in 
the morning. Now it is a fact that in certain cases of con- 
tracting kidney both albumin and casts may be absent from 
the urine voided on rising. I need not again refer to the case 
so often quoted by me, in which I failed to find either albu- 
min or casts in the early morning urine of a patient with 
retinitis albuminurica, six v/eeks before death from coma. A 
few months ago I examined the urine voided on rising by a 
man whose history was unknown to me, and found it practi- 
cally normal. Later I asked for his day urine, and found in 
it albumin, casts, Hood and pus corpuscles, and crystals. 

4. On part of the physician, too much confidence in the 
presence of a fairly large quantity of urea. I will not deny 
that in a case where the features and history point to uraemia, 
and where the patient is voiding less than two hundred grains 
of urea a day, and where the presence of casts in the urine can 
be demonstrated, that the case is indeed likely to be one of 
uraemia, but I do insist that excretion of more than two hun- 
dred grains of urea does not exclude uraemia. 

5. On part of the physician, too much reliance on the con- 
dition of the heart and pulse ; it is indeed true that an albu- 
minuria coinciding with a tense pulse and headache is signifi- 
cant usually of contracting kidney, but a good many cases of 
uraemia will be found in which cardiac and vascular features 
are by no means maiked, and there are a good many cases 



646 CLINICAL MEMORANDA AND SUMMARY. 

with marked cardiac and vascular symptoms which do not 
manifest uraemia. Uraemic poisoning, like poisoning by other 
agents, does not affect all persons alike. 

It may not be amiss to recall the fact that occasionally a 
male child is born with a prepuce so tightly adherent as to 
close the meatus completely, and thus prevent urination. In 
the case of any male infant, therefore, when urine is not 
voided after the usual period of twenty-four to thirty-six 
hours, examination of the prepuce should be made, if it has 
not been done before. 

It must also not be forgotten that prolonged cases of poly- 
uria from any cause may develop uraemic symptoms from sud- 
den and more or less complete anuria. Not long ago I saw a 
case of diabetes mellitus of two years' duration, in a young 
woman, in which death was preceded by sudden diminution 
in the quantity of urine, appearance of albumin and casts, and 
finally total suppression for a day or two, all measures for re- 
lief of which were futile. {From a paper in the Medical Vis- 
itor by the writer.) 

THE UREMIA OF ELDERLY MEN.* 

The writer has seen certain cases in which old men have 
died either comatose or in convulsions without much previous 
indication of this particular termination of their case. 

All of them, so far as known, were sufferers from enlarged 
prostate and cystitis, but the prostatic trouble was not neces- 
sarily more severe than in other patients, who as yet show no 
uraemic tendencies. 

It is difficult to discover the actual cause of the uraemia in 
some of the cases, or even to determine with exactness just 
when it sets in. It may steal upon the patient in a most in- 
sidious way, and is not likely to leave him when once it has 
become established. 

* Published in the Medical Era by the writer. 



THE URAEMIA OF ELDERLY MEN. 647 

Pyelonephritis, terminating in profound coma, is undoubt- 
edly the ultimate cause of death in a large number of prostatic 
cases, according to Goodhart, in seventy-four per cent.; again, 
hydronephrosis, with resulting chronic interstitial nephritis, 
is the cause of uraemia in other cases. But the writer has 
seen cases in which no evidences of either of these lesions was 
demonstrable, while yet the patient slowly sank and died com- 
atose. 

In order to account for these more obscure cases the writer 
advances the following hypotheses : 

First, the likelihood of the existence of forms of chronic 
nephritis, not yet well-recognized, but which are intermediate 
between typical chronic interstitial nephritis and senile con- 
tracting kidney, forms in which uraemia is a more prominent 
feature than the cardio-vascular changes which we expect to 
see in typical chronic interstitial nephritis. We find, in most 
cases of uraemia in elderly men, pale urine of low specific 
gravity, more or less deficient in solids. Urea is not invari- 
ably decreased to a marked degree, but uric acid is almost al- 
ways low. A trace of albumin is found which we commonly 
refer to the presence of pus in the sediment. Casts are usu- 
ally absent until late in the case, when a few hyaline or pale 
granular casts may be found at times. 

Inasmuch as various writers have insisted on the existence 
of forms of chronic nephritis intermediate between chronic 
interstitial nephritis and senile contracting kidney, it seems 
not unlikely that the uraemia of elderly men, which is not 
apparently due to pyelonephritis or to typical interstitial ne- 
phritis may be referred to some of these intermediate forms. 
If such a nephritis is present, it would naturally affect most 
seriously those whose skin and bowels were particularly inac- 
tive, and it is in old men with such a condition of the skin 
and bowels that the writer has observed chronic uraemia most 
frequently. 

Moreover, in cases of chronic pyelitis or cystitis eventually 



648 



CLINICAL MEMORANDA AND SUMMARY. 



proving fatal, interstitial changes in the kidneys are usually 
observed post-mortem, and though, perhaps, in some the mac- 
roscopic changes are not well marked, still a careful micro- 
scopic examination rarely fails to reveal interstitial change 
(Ralfe). The cause of this interstitial change is most com- 
monly due to pressure on the ureters of the thick bundles of 
muscular tissue of an hypertrophied bladder. Pressure on the 
ureters causes increased urinary pressure in the kidneys, and 
increased urinary pressure in the kidneys is known to be a 
cause of interstitial changes. It is possible, therefore, that in 
the cases referred to by the writer death from uraemia is due 
to the existence of an interstitial disease intermediate between 
typical chronic interstitial nephritis of middle life, without 
enlarged prostate and cystitis, on the one hand, and senile 
kidney on the other. We expect to find in typical interstitial 
nephritis, hypertrophy of the left ventricle, a high tension 
pulse, atheroma of arteries, and sometimes albuminuric retin- 
itis. But in the cases referred to above the writer has not 
noticed these conditions, the clinical features being merely 
those of chronic uraemia, together with urine of poor quality, 
showing the usual evidences of cystitis. In cases which die 
from pyelonephritis it is well known that we may find post- 
mortem evidences of chronic interstitial nephritis intermixed 
with those of suppurative changes. The writer reasons, there- 
fore, that patients with enlarged prostate and cystitis who die 
of uraemia without the usual symptoms of pyelonephritis are 
killed by some form of interstitial nephritis, before pyelone- 
phritis, on the one hand, or hydronephrosis, on the other, has 
set in. 

A second hypothesis, wholly different from the first, and 
which seems, in the light of our present knowledge, much 
less likely, is that the uraemia is due either entirely or in part 
to actual absorption of urinary salts in the bladder itself from 
residual urine there. We know, for example, from the ex- 
periments of Ultzmann that under certain circumstances the 
bladder is able to absorb certain salts. 



THE UREMIA OF ELDERLY MEN. 649 

Ultzmann found that in some cases of bladder haemor- 
rhages, if two fluidounces of a one and one-half per cent, 
solution of potassium iodide were injected into the washed- 
out bladder, iodine could be detected in the saliva fifteen 
minutes later. ( Vorlesungen neber Krajikheiten der Harnor- 
gane, Vienna, 1888.) 

A slow absorption of small quantities of urinary salts might 
also be possible in an ulcerated bladder. Until, however, we 
know just what substances are responsible for uraemic phenom- 
ena, we can not regard this hypothesis as even probable, but 
must relegate it to the domain of possibilities. Any argu- 
ment in its favor would nevertheless be welcomed by the 
writer as of great interest. 

Regardless, however, of theories as to cause, we cannot fail 
to notice that certain old men with enlarged prostate or with 
more or less cystitis and pyuria die from some sort of chronic 
poisoning, which, in a general way, we call uraemia. For 
some time previous to death the family and friends of a pa- 
tient in this condition notice the change in him. They say, 
"The old man is failing — he is not what he used to be." 

Dull headache, bodily and mental lassitude, and inertia pre- 
dominate. The patient's face becomes expressionless and in- 
different. He does not always know just where he is or what 
he is doing. He may wander about the streets for hours with- 
out definite purpose or accomplishment. He rouses when 
spoken to and may reply rationally to questions put to him, 
but gradually sinks into stupor when left to himself. After a 
length of time, varying in different cases, he becomes coma- 
tose, and all efforts to rouse him are then usually futile. In 
some cases agonizing headaches, rather than stupor, occur, 
and death is preceded by convulsions. 

The problem of the therapeutic management of such cases 
seems to be difficult of solution and about the only hope to lie 
in persistent though gentle eliminative measures in cases 
where operative proceedings are not feasible. 



650 CLINICAL MEMORANDA AND SUMMARY. 

The accumulation of toxic products is persistent, so that 
efforts to get rid of them must also be persistent. When we 
find an elderly patient with obstruction to the free flow of 
urine, with a bad tongue, a bad breath, constipated bowels, a 
dry, harsh, inactive skin, who is voiding pale urine of low 
specific gravity, deficient in solids, especially in uric acid, and 
containing pus, whether or not we can satisfactorily make the 
diagnosis of renal disease, it is incumbent upon us to make 
constant effort to promote elimination. This is not always 
easy, for so-called vigorous measures may seriously weaken 
the patient. Removal to a more equable climate than ours, 
where he can have plenty of sunlight, and gentle exercise in 
the open air, followed by careful, not too vigorous, bathing 
and expert massage is to be recommended. 

The writer has seen a number of drugs used in large and 
small doses in the various cases, but cannot report flattering 
results from any save in one or two instances where Jaborandi 
seemed to be of benefit. 

It would appear from the above and from the fact that 
death from pyelonephritis or contracting kidney also awaits 
the patient with enlarged prostate, that operative removal of 
the obstruction to the free flow of urine should be undertaken, 
as Adams advises, as soon as retention from obstruction takes 
place. 

SEQUENCES AND COMPLICATIONS OF URINARY DISEASES. 

Among the more common sequences and complications of 
urinary diseases we find the following : 

i. A movable kidney may cause kinking of the ureter, hy- 
dronephrosis, pyonephrosis and pyelonephritis. 

2. Injury to the urethra, or even the passage of a sound, 
may be followed by acute hyperemia of the kidneys, suppres- 
sion of urine, coma, and death in less than fifty hours. 

3. Long-lasting acute renal hyperemia is likely to result in 
acute nephritis. 



COMPLICATIONS OF URINARY DISEASES. 651 

4. Polyuria from any cause may result in acute hyperemia. 

5. Repeated attacks of acute hyperemia may precede the 
onset of renal tuberculosis. 

6. Long-continued chronic renal hyperemia may finally re- 
sult in a fatal chronic nephritis. 

7. Acute nephritis may be followed by chronic nephritis, es- 
pecially chronic diffuse nephritis. 

8. Chronic diffuse, 7ion-indurative nephritis may follow dis- 
eases of the lower urinary tract and malignant growths. 

9. Cases of chronic diffuse nephritis (large white kidney), 
which do not recover after a year or two, may suffer from 
renal atrophy (atrophic stage of large white kidney, secondary 
interstitial nephritis). 

10. An unrecognized case of chronic diffuse nephritis may 
suddenly exhibit the symptoms of an acute hcsmorrhagic ne- 
phritis. 

11. Long-lasting stricture of the urethra may be followed 
by primary chronic fibrous (interstitial) nephritis (contracting 
kidney). 

12. Displacements of the uterus, resulting in pressure on 
the ureter, may be followed by hydronephrosis, pyonephrosis 
and pyelonephritis, or by contracting kidney. 

13. Contracting kidney may be the result of calculous pye- 
litis. 

14. Contracting kidney by distal constriction of the urinif- 
erous tubules may cause proximal dilatation of them by the 
urine and formation of cysts {multilocular cystic kidney). 

15. Chronic diffuse nephritis (either large or atrophied kid- 
ney) or chronic fibrous ?iephritis (contracting kidney) may 
either of them become complicated by lardaceoits degenera- 
tion (amyloid kidney). 

16. Lardaceous degeneration may follow pyonephrosis and 
para7iephric abscess. 

17. Chronic diffuse non-indurative nephritis complicated by 
lardaceous degeneration may result in suppurative nephritis in 
one kidney. 



652 CLINICAL MEMORANDA AND SUMMARY. 

1 8. Lai'daceous degeneration may have nephritic complica- 
tion. 

19. Diseases of the lower urinary tract or surgical operations 
on the same may result in abscess of the kidney (pyelone- 
phritis). 

20. Abscess of the kidney may extend to the paranephric 
fatty tissue, causing paranephric abscess. 

21. Renal abscess or paranephric abscess may communicate 
with the renal pelvis, causing pyelitis. 

22. Chronic renal tuberculosis may cause paranephric ab- 
scess. 

23. In women pelvic cellulitis may be followed by parane- 
phric abscess. 

24. Paranephric abscess may follow surgical operations on 
the testicle and spermatic cord after inflammation of the con- 
nective tissue about the bladder ; or it may follow operations 
on the rectum, perinseum or uterus. 

25. Suppurative processes in the gall-bladder, liver and 
spleen may be followed by paranephric abscess. 

26. Renal tuberculosis is often preceded by tuberculosis of 
the testicle, epididymis or prostate. 

27. Chronic inflammation of the lower urinary tract may 
be followed by ascending tuberctdosis. 

28. Renal tuberculosis in one kidney may descend through 
the ureter to the bladder and ascend to the other kidney. 

29. Primary malignant disease of the testicles may cause 
secondary malignant disease in the kidneys (cancer). 

30. Large retroperitoneal tumors may cause absorption of 
the kidney and replacement by fat. 

31. Diabetes mellitus may cause pyelitis from irritation by 
saccharine urine. 

32. An abscess breaking into the renal pelvis may cause 
pyelitis by irritation ; as may the presence of a foreign body in 
the pelvis of the kidney. 

33. Failure to avoid sepsis after operations on the urinary 



COMPLICATIONS OF URINARY DISEASES. 653 

tract may be followed by pyelitis ; childbirth may also be a 
cause. 

34. Acute nephritis may result in pyelitis due to bacterial 
irritant. 

35. The colon bacillus may cause pyelitis, and this disease 
may follow even habitual constipation. 

36. Pyelitis is sometimes a result of gonorrhoea, and of 
many infectious diseases. 

37. Pyelitis is frequently followed by pyelonephritis. 

38. Chronic pyelitis of long duration may be followed by 
lardaceous degeneration or chronic fibrous nephritis (contract- 
ing kidney, primary chronic interstitial nephritis). 

39. Hydronephrosis may follow urethral stricture, enlarged 
prostate, renal calculus or displacements of the kidney ; spas- 
modic contraction of the ureter is a noteworthy cause. 

40. An operation on the lower urinary tract in a patient 
with hydronephrosis may be followed by fatal pyelonephritis. 

41. Chronic fibrous nephritis (contracting kidney) follows 
the dilatation of the pelvis in hydronephrosis, particularly in 
a double hydronephrosis with progressive enlargement. 

42. Pyonephrosis may follow from the same causes as hy- 
dronephrosis, and especially from stone impacted in the pelvis 
of the kidney. 

43. Malignant disease of organs near the kidney may be 
followed by pyonephrosis. 

44. Renal calculus may result, if not removed, in serious 
renal inflammations and degenerations. The kidney may be- 
come a mere shell about the stone. 

45. Impaction of the stone in the ureter may lead to ulcera- 
tion, perforation, abscess and death from peritonitis. 

46. Ureteritis in women may be followed by spasm of the 
ureter (renal tenesmus). 

47. Ureteritis may follow either pyelitis or diseases of the 
lower urinary tract. 

48. Cystitis may result from gout (hyper-acid urine) or from 
diabetes mellitus (saccharine urine). 



654 CLINICAL MEMORANDA AND SUMMARY. 

49. Slight cystitis may follow any infectious disease in 
which a slight degree of acute nephritis exists. 

50. Cystitis may commonly follow gonorrhoea (irritation 
from the gonococcus). It may be due to extensio7i of inflam- 
mation in the urethra or prostate, especially when an unclean 
catheter is used ; it will result from retention of urine from 
any cause, and from presence of stone or foreign body. 

51. Injury \s a common cause of cytsitis ; a common injury 
is pressure from the foetal head. Pressure from feces or pes- 
saries may cause it, or from a displaced uterus. 

52. Cystitis may result in prevesical inflammation. 

53. In women anal and rectal inflammations are quite com- 
monly followed by cystitis. 

54. Fissure in the neck of the bladder in women is a com- 
mon cause of symptoms erroneously referred to cystitis proper. 

55. In pregnant women a chronic congestion of the urethra 
is not uncommon. 

56. Residual urine is likely to be followed by formation of 
stone in the bladder. 

57. Stone in the bladder may ultimately be followed by 
death from pyelonephritis, or by abscess formation in and 
about the bladder. 

58. Vesical tuberculosis may result either from renal tuber- 
culosis or by infection from the prostate and seminal vesicles. 
More commonly it results from surface inoculation by the 
stream of tuberculous urine from the kidney or renal pelvis. 

59. Tumors of the bladder about the ureteral orifice may 
result in hydro- and pyonephrosis, pyelonephritis or contracting 
kidney. 

60. Bladder tumors, unless removed, inevitably result in 
death. 

61. Acute prostatitis may result from irritation or sexual 
excess, but more commonly from gonorrhoea or stricture. 

62. Acute prostatitis may be followed by abscess or by 
chronic prostatitis. 



COMPLICATIONS OF URINARY DISEASES. 655 

63. In tubercular subjects a severe chronic tubercular pros- 
tatitis may be noticed. 

64. Enlargement of the prostate results in distortion of the 
prostatic urethra, elevation of the level at the vesico-urethral 
orifice, and obstruction to the return of blood from the blad- 
der. 

65. Enlargement of the prostate may be, therefore, followed 
by retention of urine, cystitis and vesical stone. 

66. Enlarged prostate may result in a slight chronic ureter- 
itis and pyelitis. 

67. Use of the catheter may result in urinary fever or in 
swelling of one or both testicles. 

68. Enlarged prostate results sooner or later in dilatation 
of the bladder, hypertrophy of it, dilatation of the ureters and 
renal pelvis, with stagnation of urine, congestion and catar- 
rhal inflammation of the entire urinary tract, pyelonephritis, 
and death from profound coma. 

69. Cases of enlarged prostate may be complicated by 
chronic fibrous nephritis (contracting kidney). 

70. In enlarged prostate death from urcsmia is sometimes 
noticed in patients who have not manifested marked evi- 
dences of renal disease. (See writer's paper "Urczmia of 
Elderly Men.") 

71. Irregular or ungratified sexual desire may result in a 
frequent desire to urinate without presence of any inflamma- 
tory disease ("Neuralgia" of the bladder, irritability of the 
bladder). 

72. Diabetes mellitus may cause diminution of sexual in- 
clination, disorders of the cutaneous surface, asthma, gastric 
catarrh, constipation, cystitis, muscular pains, cataract, gan- 
grene, retinitis, insanity, chronic nephritis and coma. It may 
be cut short by death from chronic pulmonary tuberculosis or 
acute p7ieui?io?iia. 

73. Diabetes insipidus may lead to exhaustion from loss of 
rest, thirst and worry. 



656 CLINICAL MEMORANDA AND SUMMARY. 

74. Various diseases of the urinary tract may be due to ir- 
ritation from use of drugs, either internally or by injection : 

Acute hypersemia and acute nephritis to Cantharides, Tur- 
pentine, Juniper, Squills, Nitre, Copaiba, Cubebs, Mineral 
acids, Oxalic acid, Carbolic acid, certain salts of Potash 
(Chlorate, Chromate, Iodide), Phosphorus, Arsenic, Corrosive 
sublimate, Oil of Mustard, Salicylic acid, Coal-tar compounds, 
Boracic acid, Opium, sharp condiments ; to external applica- 
tions of Carbolic acid and Iodoform ; to frictions with Tar, 
Storax, Peru balsam, Petroleum, Naphthol, Chrysarobin, Py- 
rogallic acid ; to various ointments used in scabies and psori- 
asis. 

Acute nephritis may follow ptomain poisoning. 

Chronic nephritis would appear to be a sequence of alcohol- 
ism in some cases. 

Chro?iic nephritis (contracting- kidney) is often a result of 
plumbism and of chronic poisoning by other metals. 

Pyelitis may result from elimination of such poisons as Co- 
paiba, Turpentine, Cantharides or Cubebs. 

Cystitis may also be due to the same, or even to mustard or 
certain kinds of beer ; strong injections may cause it. 

Acute prostatitis may be caused by Cantharides or other 
drugs, and by strong injections. 

75 Bacterial irritants, toxins, etc., are a fruitful cause of 
renal diseases, as follows : 

Acute hyperemia: It is possible that xanthin and paraxan- 
thin may have something to do with death from suppression 
of urine in acute hypersemia. 

Acute nephritis is commonly due to the passage of soluble 
specific virus through the kidneys, i. e., to products elimi- 
nated by pathogenic microbes ; and also to sepsis. 

Chronic nephritis (contracting kidney) is often referable to 
syphilis, malaria or gout. 

Lardaceous disease is recognized as the result of the long- 
continued action of toxins produced by the staphylococcus 
pyogenes aureus. 



COMPLICATIONS OF URINARY DISEASES. 



657 



Puerperal nephritis is thought to be a toxaemia in some 
cases, but many theories exist regarding it. 

Renal abscess is due either to the entrance of pyogenic bac- 
teria from the circulation or to extension of inflammation 
from below. 

Paranephric abscess and genito-urinary tuberculosis may be 
included in the same general category as the above. 

Pyelitis may be due to the action of the colon bacillus or to 
the bacterial irritants of various infectious diseases. 

Pyonephrosis may sometimes be septic or due to bacterial 
irritants. 

Cystitis may be due to the local action of the bacteria or 
toxins of its primary disorder. 

Acute prostatitis is often due to the action of the gonococ- 
cus. 

INDEX TO THE ABOVE. 
Abscess of the Kidneys, see Pyelone- Movable Kidney, i 
phritis. 



Abscess of the Bladder, 57 

Abscess of the Prostate, 62 

Atrophy of the Kidneys, 9 

Calculus, Renal, 44, 45 

Calculus, Vesical, 56, 57, 65 

Cancer, Renal,- 29, 44, 45 

Cancer, Vesical, 50 

Contracting Kidney, 11, 12, 13, 14, 
38, 41, 69 

Cystic Kidney, 14 

Cystitis, 48, 49, 50, 51, 52, 53, 65, 74, 75 

Diabetes, 31, 48, 7 2 > 73 

Enlarged Prostate, see Prostatic Hy- 
pertrophy. 

Floating Kidney, see Movable Kid- 
ney. 

Hydronephrosis, 1, 12, 39, 40, 41 

Hyperaemia, Acute, 2, 3, 4, 5, 74, 75 

Hypersemia, Chronic, 6 

Lardaceous Degeneration, 15, 16, 17, 
18, 38, 75 



Nephritis, Acute, 7, 10, 34, 49, 74, 75 
Nephritis, Chronic, 7, 8, 9, 10, 11, 12, 

13, 14, 15, 17, 38, 41, 69, 74, 75 
" Neuralgia " of the Bladder, 71 
Paranephric Abscess, 16, 20, 21, 22, 

23, 24, 25, 75 
Prostatic Hypertrophy, 64, 68, 69, 70 
Prostatitis, 61, 62, 63, 65, 74, 75 
Puerperal Nephritis, 75 
Pyelitis, 13, 31, 32, 33, 34, 35, 36, 37, 

38, 47, 66, 74, 75 
Pyelonephritis, 1, 12, 17, 19, 20, 21. 

37, 40, 57, 68, 75 
Pyonephrosis, 1, 12, 16, 42, 43 
Renal Tenesmus, 46 
Stone, see Calculus. 
Stricture, 11, 61 

Tuberculosis, Renal, 22, 26, 27, 28 
Tuberculosis, Vesical, 58 
Urethritis, 46, 54, 55 
Ureteritis, 45, 46, 47, 66 
Urinary Fever, 2, 67 



(From an article by the author in the Hahnemannian.) 
42 



658 CLINICAL MEMORANDA AND SUMMARY. 



EXAMINATION OF THE URINE AS AN AID TO PROGNOSIS. 

Examination of the urine furnishes us in various ways with 
means by which we may form an opinion as to the outcome of 
diseases. The following are among the most important con- 
ditions in which knowledge of the character of the urine is of 
value as an aid to prognosis : 

The Prognosis in Renal Diseases : — In acute hyperemia, 
especially that following surgical operations, the prognosis 
depends on the quantity of urine and its character. Sup- 
pression of urine continuing for several days after an op- 
eration is a bad sign, the cases usually terminating fatally. 
Cases in which the urine is scanty (less than ten fluidounces 
in twenty-four hours) and highly albuminous (twenty to 
thirty per cent, bulk), with a good deal of blood, are dubious, 
and demand a guarded prognosis, which becomes favorable as 
the urine increases, while albumin and blood diminishes. 

In chronic hypercemia the prognosis depends on the cura- 
bility of the disorder causing the chronic congestion. As to 
immediate prognosis, however, much depends on the examin- 
ation of the urine. The writer has noticed the tendency of 
chronically congested kidneys to take on inflammation, shown 
by increase of albumin and presence of granular casts. When, 
in the course of a chronic congestion, therefore, we find albu- 
min more than ten per cent, bulk, and granular casts, espe- 
cially dark ones, present, the prognosis becomes unfavorable 
as regards time. In several cases the writer has observed no 
signs of nephritic complication until a few weeks or days be- 
fore death from uraemia in cardiac failure, but the complica- 
tion must, as a rule, be regarded as a grave one. 

In acute post-scarlatinal 7iephritis the immediate prognosis 
depends on the quantity of urine, albumin, blood and casts. 
When the quantity of urine per twenty-four hours falls below 
ten ounces, when albumin is abundant, blood and casts ditto, 



PROGNOSIS FROM EXAMINATION OF THE URINE. 659 

the prognosis must be guarded, becoming favorable as the 
urine increases and the constituents above named decrease. 
During convalescence moderate polyuria is often observed, 
but if the quantity of urine remain above normal, the specific 
gravity low, and albumin and casts (especially granular and 
fatty) persist, the prognosis again becomes dubious, on ac- 
count of danger of chronic nephritis. [It is possible to find 
a trace of albumin and a few hyaline casts for months in cases 
which ultimately recover completely. In one of the writer's 
cases such was the condition for nine months after the origi- 
nal appearance of albumin, but the urine was normal in other 
respects.] 

A particularly fatal form of acute nephritis is sometimes 
seen, in which blood and blood-casts are absent, but albumin 
and casts (not blood-casts) usually abundant. This form is 
called by Porter acute parenchymatous degeneration, and is 
always the result of toxic influences, whether from poisoning 
by various drugs or caused by toxins in the body. The prog- 
nosis in these cases is invariably grave, whereas in the usual 
post-scarlatinal cases two out of three recover. These degen 
erative cases occur sometimes in the course <9/~(not necessarily 
after) infectious diseases, and the albumin is not always large 
in amount, but may be only a trace. 

In chronic diffuse non-indurative nephritis the prognosis de- 
pends largely on the condition of the urine after the patient 
has suffered for a year from the disease. If the amount of al- 
bumin and the number of casts, especially fatty, are great at 
the expiration of a year, the chances are that the patient will 
not live more than a year, or two more at most, especially if 
the dropsy is obstinate, resisting all efforts on part of the phy- 
sician to cause its disappearance. The writer has seen sev- 
eral complete recoveries from this disease in cases less than a 
year old, and, as a rule, refrains from giving an unfavorable 
prognosis, even in apparently desperate cases, before this 
space of time has elapsed. 



660 CLINICAL MEMORANDA AND SUMMARY. 

Some few cases linger several years, and the urine, instead 
of being below normal in quantity, becomes abundant, pale, 
of low specific gravity, albuminous still, and containing nu- 
merous casts. The prognosis is ultimately unfavorable, as 
the kidneys are undergoing atrophy in some parts, and life 
depends on the degree of compensatory hypertrophy of it. 

In chronic primary interstitial nephritis (contracting kid- 
ney) while the ultimate prognosis is unfavorable, it is ex- 
tremely difficult to predict which way the case is going at 
any given time, on account of the suddenness of the uraemic 
attacks. The writer has seen cases in which uraemic attacks 
occurred with but little warning from the condition of the 
urine. In general, however, since polyuria is the rule in both 
cases, diminution in the quantity of urine with increase in 
color, while at the same time the specific gravity is below 1013, 
is an unfavorable combination. The writer had opportunity 
to examine the morning urine of a patient who died the same 
day of uraemia. The amount of albumin was a trace merely, 
and only three or four casts were found ; but the color of the 
urine was darker than normal, suggesting a specific gravity of 
1025 or m °re, when in reality it was only 10 13. 

In lardaceous disease (amyloid degeneration), when the us- 
ually scanty sediment becomes more abundant, and instead of 
containing a few broad hyaline or waxy casts, now shows 
granular and fatty ones, nephritic complication has set in, and 
the prognosis, which before was dependent on the exciting 
cause (suppurative processes in the body) now becomes unfav- 
orable in all respects. 

In several fatal cases of chronic nephritis the writer has ob- 
served a marked indican reaction not long before death. 

During pregna7icy the writer finds instructive lessons in 
prognosis. In cases with history of previous convulsions or 
of neurotic family history, the prognosis is guarded, becoming 
unfavorable either to child or mother, or both, when the urine 
diminishes suddenly in quantity, when urea increases in 



PROGNOSIS FROM EXAMINATION OF THE URINE. 661 

grains per ounce, and albumin increases greatly in bulk. 
The lesson from casts is not always of value. In one of the 
worst cases of convulsions the writer ever saw, there were but 
few casts to be found, and these small, hyaline in kind. The 
peculiarity of the puerperal cases is that the percentage of 
urea (grains per fluidounce) is often high (twelve to seven- 
teen grains), whereas in the ursemic attacks of true nephritis 
the relative quantity of urea is usually low, or at least below 
normal on a basis of forty ounces per twenty-four hours. The 
books say a urea is diminished" in puerperal nephritis, so- 
called, and so it is in quantity per twenty-four hours ; but the 
writer has observed in three or four fatal cases a high percent- 
age of urea in grains per ounce a day or two before death. 

Whether this increase in percentage of urea is merely a 
sign of deficiency of water or not is difficult to say. Some 
who discuss the matter with the writer regard it as of no diag- 
nostic or prognostic importance, but in the writer's judgment 
the increase in grains per ounce of urea is to be regarded as 
an evidence of an effort of the body to get rid of urea and of 
toxins, and such increase is usually out of proportion to the 
diminution in the quantity of urine, accompanied as it often 
is by remarkable deficiency of other solids, so that the ratio of 
urea to salts is two to three times as high as normal. The 
writer regards, then, an increase of urea (in grains per ounce 
above ten), coupled with a high ratio of urea to salts, and a 
great increase in the percentage of albumin, a sign of impend- 
ing convulsions during pregnancy. 

Leaving renal diseases and turning to other disorders, we 
find here and there useful hints in prognosis from examina- 
tion of the urine. 

i. In diseases in which there is exudation, like pneumonia, 
marked increase in the quantity of solids in the urine is a 
good sign, indicating, as it does, that elimination is not de- 
fective. 

2. In exudative disorders, and also in fevers and acute dis- 



662 CLINICAL MEMORANDA AND SUMMARY. 

eases like typhoid fever, a high temperature with deficient 
excretion of solids in the urine is a bad sign, indicating de- 
fective elimination. (See Urinary Analysis by writer, pages 
30 to 35, for methods of determining the solids in urine.) 

3. Women who pass less than 300 grains of total solids are 
in a serious condition, since bronchitis, neuralgia, perimetritis 
or pleurisy may result from taking cold. 

4. In diabetes mellitus the red reaction with ferric chlorid 
in the urine is a bad sign, indicating as it does approaching 
coma. Whenever the physician finds sugar decreasing in the 
urine of a patient with diabetes mellitus, test for diacetic acid 
and also for albumin, and examine carefully for casts. The 
writer has seen several cases in which reduction in the quan- 
tity of sugar was not followed by improvement, but the re- 
verse. Either diacetic acid appeared, or else the patient be- 
came nephritic. In the latter case the prognosis, though ul- 
timately unfavorable, is not so bad as to time as when diacetic 
acid appears. 

The writer has found fatality in diabetes mellitus associated 
with increase in the quantity of urea. That is to say, the 
prognosis as to time is not so good in a case passing 900 
grains as in one passing 350 to 500. The quantity of urea 
evidently in such cases is an index of tissue destruction. 

5. In Addisoii's disease the writer deems the ratio of urea 
to phosphoric acid of diagnostic and possibly of some prog- 
nostic importance. In one case (confirmed post-mortem) 
which the writer had under observation for several years, this 
ratio increased as the patient grew worse, becoming above 
twenty to one at times. 

6. In diseases of the stomach and intestines Rosenbach's re- 
action, when constant and continued in spite of medical ef- 
forts, is of bad prognostic significance (Urinary Analysis, page 
124). 

7. In typhoid fever haematoporphyrinuria is deemed a bad 
sign. Urine containing haematoporphyrin presents an abnor- 



PATHOLOGY OF NON-SUPPURATIVE RENAL LESIONS. 663 

mal color, ranging from sherry or port wine tint to Bordeaux- 
red. This color is noticed in the urine of patients taking 
sulfonal. 

8. In typhoid fever the presence of pathological urobilin is 
held to indicate hepatic incompetence, and is a bad sign (Uri- 
nary Analysis, page 238). 

9. In phthisis pulmonalis continued presence of the diazo 
reaction is of bad omen (Urinary Analysis, page 242). (From 
an article by the author in the Medical Visitor.) 

THE GROSS PATHOLOGY OF NON-SUPPURATIVE 
RENAL LESIONS. 

For the convenience of students the following table has 
been arranged : 



664 



CLINICAL MEMORANDA AND SUMMARY. 



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COLLECTION OF URINE FOR EXAMINATION. 665 

In making post-mortem examinations, Nos. 3, 7, 8, 9, 10, 
and 13 are frequently called cyanotic kidney, large white kid- 
ney, small white kidney, small red or granular kidney, and 
waxy kidney, respectively. 

CLINICAL NOTES. 

The following clinical notes have been made by the author 
since the body of the book went to press : 

THE COLLECTION OF URINE FOR EXAMINATION. 

It must be borne in mind by any one who examines " a 
bottle of urine " that his report is assumed by the patient to 
indicate the general character of the latter's urine. If there 
is " nothing the matter " with the " bottle of urine " the pa- 
tient assumes that there is " nothing the matter " with any 
urine voided by him. Hence the necessity for care in 
collecting the urine for examination and the desirability of 
making repeated examinations. 

The writer has, for fifteen years or more, urged patients 
and physicians to collect the twenty-four hours' urine for ex- 
amination, keeping the day urine apart from the night and 
furnishing also in addition a sample of urine voided as 
recently as possible. Nurses should be taught to practice the 
same method of collection in cases under their care, and it 
should not be assumed by the physician that the nurse knows 
how to collect the twenty-four hours' urine properly. 

In cases of suspected intermittent albuminuria and glyco- 
suria, if nothing abnormal is found on some one day, repeated 
examinations should be made. 

The writer in some cases requests patients to furnish the 
urine of each micturition for the twenty-four hours' collection 
in separate bottles and labeled with the hour the urine was 
voided. It is unfortunately true that some cases of kidney 
disease may not on certain days show evidences in the urine 



666 CLINICAL MEMORANDA AND SUMMARY. 

of the serious condition present. The utmost care is neces- 
sary in order to prevent mistakes. If an examiner known to 
be competent has at any time found albumin and casts or 
sugar in the urine of a patient, the writer advises extreme 
caution in assuming that *a mistake has been made and that 
the patient is healthy, even if nothing indicating the contrary 
can be found in subsequent examinations. 

Every now and then a patient who is a great water drinker 
sends his urine for analysis. In such urine it is hard to pro- 
cure much sediment even by use of the centrifuge, and a few 
tube casts may be easily overlooked unless an unusual num- 
ber of slides be examined. It is always advisable, when the 
patient collects his twenty-four hours' urine, for him not to 
drink any more water than is absolutely necessary to quench 
his thirst, in order that the urine shall not be too much di- 
luted ; it is also desirable that he take the usual amount of 
exercise, for the latter, as a rule, tends to cause the appear- 
ance of albumin and tube casts in greater amount than when 
the patient is at rest. 

The lesson from these cases can be summed up in the fol- 
lowing advice : When you examine the urine of a patient have 
him collect the entire quantity for twenty-four hours, day and 
night, in separate bottles, and an extra sample voided just be- 
fore the examination is made. Examine these three samples 
separately for albumin, sugar and casts ; then mix the day 
and night samples, and make the usual quantitative analyses for 
urea, uric acid, and so on. If your examination is negative 
as regards albumin, sugar and casts, but there is reason to 
suspect that at some time or other, one or more of these con- 
stituents has been present, make repeated examinations, es- 
pecially of urine voided during the daytime or when for any 
reason the patient is fatigued. If the patient is in the habit 
of dissipating or of dining out and eating heartily, ask for the 
urine passed during the twenty-four hours following such in- 
dulgence. {Article by the author in The Homoeopathic Student.) 



CRYOSCOPY. 667 



CRYOSCOPY. 



Allusion has already been made to the use of cryoscopy in 
the diagnosis of ursemia. 

The method of determining the freezing point of urine by 
Beckmann's apparatus is as follows : 

A thermometer capable of being read to 0.001 C, is sup- 
ported by a cork in a large test-tube (A) containing the urine. 
The thermometer is arranged so that its bulb is entirely 
covered by the urine and does not come closer than 5 mm. to 
the walls of the tube. Through this cork also passes a rather 
stiff wire for stirring the urine. Sollmann recommends a 
rolled-gold wire wound in the form of a spiral, as the most 
useful. This test-tube fits through a cork into a somewhat 
wider tube (B), which in turn is supported by an appropriate 
device in a jar containing a mixture of cracked ice and salt 
of a temperature about -5 C. The Beckmann's ther- 
mometer is graduated into 0.0 1° C, but the freezing point is 
arbitrary and must be controlled daily by testing it on dis- 
tilled water, or more conveniently a standardized one per 
cent, solution of sodium chloride, as below. 

To determine the freezing point of any liquid with the ap- 
paratus the tube (A) is plunged directly into the freezing 
mixture, stirring the tube steadily with the wire. The freez- 
ing mixture is also stirred occasionally. The mercury will 
be seen to recede from the reservoir and descend into the 
stem ; at a certain point it will suddenly reverse its direction 
and ascend. The tube is now removed from the freezing 
mixture and (B) is set into the mixture. The stirring of (A) 
is meanwhile continued. The urine is seen to be filled with 
small crystals of ice. It will be noted that the mercury soon 
comes to a standstill, which approximately corresponds to 
the freezing point of the liquid. The stirring is continued 
until the ice is almost but not quite completely melted. Care 



668 



CLINICAL MEMORANDA AND SUMMARY. 



should be taken that the mercury does not rise more than 
o.2° C. above the freezing point. When the ice has melted 
sufficiently the tube is plunged for a moment into the freez- 
ing mixture, and is then set into the tube (B) which in its 
turn rests in the freezing mixture, the stirring being con- 
tinued. The point at which the mercury remains constant is 
the freezing point. The tube (A) is taken out again, stirred 
until the greater part of the ice is melted, and the freezing 
point is taken as before. The two determinations should 
agree to 0.003 ° £., Dut one agreement of 0.002 ° C. is suffi- 
cient for most clinical examinations. Thermometers with 
fixed freezing points, while not so delicate, are yet suffi- 
ciently accurate for clinical work. 

The depression of the freezing point below that of water is 
denoted by the sign A. The normal variations of this de- 
pression for urine lie usually between 0.9 and 2.1 C, es- 
pecially if the quantity of the urine is between 900 and 1700 
C.c; exceptionally A may range between o.i° and 3 C, even 
in healthy individuals. A X C.c. of urine in 24 hours gives 
the measure of the gram-molecules (molecular weight of sub- 
stance expressed in grams) excreted per day, the value of 
which in normal individuals lies between 770 and 3,560; 
mean, 1,700. This factor shows the output of molecules in 
the 24 hours; it varies with the activity of the kidneys, with 
the activity of the circulation, and with the metabolism or 
salt income. Sollmann thinks the most useful factors for 
clinical purposes may be expressed by the following tables, 
when the patient is on a diet which contains a normal and 
fairly constant quantity of common salt, NaCl : 







Quantity. 


A 


AX C.c. 


NaCl % 


A 




NaCl % 


Usual variations . 


•{ 


800 to 
1500 C.c. 


0.92 to 
2.14 


900 to 
2000 


0.4 to 

1.2 


0.4 to 
1.2 



CRYOSCOPY. 



669 





N% 


Per Day. 
NaCl. 


Per Dav. 

N 


Usual variations . . 


i.o to 

2.0 


8.0 to 
15.0 


10 to 

20 



According to Sollmann the most characteristic differentia- 
tion of renal disease from heart disease is that in renal dis- 
ease and A x C.c. and A all tend to be lowered ; whereas 



NaCl 



in circulatory changes N ™ and A vary inversely to A X C.c. 

When a low A exists, especially when associated with a low 

A 
A X C.c. and a low ^Cl' ^ e evidence is fairly strong in 

favor of renal disease. 

If such is not the case, nephritis cannot be excluded. In- 
deed, the normal limits are so large that cryoscopy cannot be 
considered a delicate method of diagnosing renal disease. 

The value of the method is much greater if instead of 
" nephritis " we use it to investigate the competence of the 
kidney. Thus, a low A x C.c, and especially a low S x C.c, 
indicates a deficient secreting power for urea ; (8 = A — [% 

A 
NaCl X 0.61]): high, A X C.c, with low ^aCl an increased 

permeability of the kidney, etc., according to the scheme 
given above. The following tabulation may also prove help- 
ful : 

Significance of Changes of Physical Factors. — Low A : Diuresis; lessened 
absorbing power of the kidney; lessened metabolism (starvation). 

High A : Efficient absorbing mechanism; water withdrawal. 

Low A X C.c: Slowed renal circulation (cardiac disease) ; impermeability 
of renal epithelium of glomerulus; low metabolism (starvation); salt with- 
drawal; water withdrawal. 

High A X C.c: Efficient function of the kidney; abnormal permeability 
of kidney; increased metabolism; salt administration. 



670 CLINICAL MEMORANDA AND SUMMARY. 

Low ^ • Diuresis; salt administration; deficient absorbing power of 

the kidneys; inefficient power of excreting urea; deficient nitrogen meta- 
bolism. 

High Tf^ : Salt withdrawal; starvation; slowed renal circulation (car- 
diac disease); increased nitrogen metabolism; impermeability of glomerulus. 

The composition of the urine is merely an aid to diagnosis. 
Considered as such, it will well repay the investigator. But 
if any one approaches the subject of cryoscopy with the ex- 
pectation that it will solve on every patient the questions of 
physiology and pathology which have so far withstood even 
post-mortem investigation and direct experiment, he is doomed 
to disappointment. 

Urcemia. — The cryoscopic changes in uraemia do not appear 
before clinical symptoms, are not quite constant, and have, 
therefore, very small diagnostic value. Much more can be 
judged from the A of the blood ; an increase of this almost 
invariably occurs, and is proportional to the gravity. V. 
Koranyi found it normal in a few days of his fatal cases, but 
this altogether exceptional, and can scarcely be considered true 
uraemia. The urine was found by Claude and Balthazard 

to show very low A X C.c. and 8 x C.c. is usually low, 

NaCl 

but may be rather high when the circulation has become 

greatly slowed. 

Cryoscopy of Urine as a Means of Surgical Diagnosis. — 
According to Waldvogel one of the most valuable features of 
cryoscopy is to determine the efficiency of the kidneys when 
one of them is to be excised, and in relieving the anxiety of 
the surgeon when this excision has been performed. 

He states that if the urine possesses a A superior to i.o, 
excision of one kidney may be safely done. After the ex- 
cision the A and a X C.c. are abnormally low for a day in 
any case, but if the remaining kidney functionates properly, 
they should recover their normal value on the following day, 



CRYOSCOPY. 671 

and after that for some days they are abnormally high. But 
if the A and especially the A X C.c. do not recover after this 
second day, there must be grave fears that the remaining kid- 
ney is also diseased. 

The Clinical Value of Cryoscopy. — Dr. Gaetano Florio 
(Gazetta degli ospedali e delle cliniche, July 6th) concludes as 
follows as regards the clinical significance of cryoscopic exam- 
inations : The cryoscopic examination of urine gives very im- 
portant clues as to the functional state of the kidneys. The 
urine of twenty-four hours should be collected for the freez- 
ing test, but it is not necessary to obtain the urine from each 
kidney by ureteral catheterization. The freezing point of 
urine taken from the bladder in a case of unilateral renal 
disease is different from that of a case in which the lesion is 
bilateral. When one kidney is diseased, the freezing point 
does not reach below 0.95, while, when both are diseased, it is 
nearer to 0.45 or 0.30. The proteid substances, such as albu- 
min, pus, etc., do not take part like the crystalline substances, 
in influencing the freezing point in the urine, and therefore 
cryoscopy offers a means of differentiating most readily cystitis 
from pyelitis and pyelonephritis. This fact also explains the 
independence of the freezing point from the specific gravity, 
which may be increased by the proteid substances. 16 

On the Elimination of Urinary Products in Chronic Inter- 
stitial Nephritis. — Dr. Claude, of Paris, at a recent meeting 
of the Hospital Society of that city, after alluding to the gen- 
erally-accepted view that in chronic interstitial nephritis renal 
permeability is diminished, reported the results of the re- 
searches of Dr. Burthe and himself in this condition. They 
employed both cryoscopy and chemical analysis. They found 
that, on the contrary, the elimination of renal products is 
rather increased for a long time, and only towards the end of 
the disease does the quantity fall. Complications may bring 
about the same result. This is easily explained by a study of 
the evolution of these lesions. As is known, there is a pro- 



672 CLINICAL MEMORANDA AND SUMMARY. 

gressive development of interstitial tissue in the kidneys, 
with a confluence of islets of sclerosis which were at first dis- 
seminated. Simultaneously the blood-pressure rises and the 
heart becomes hypertrophied. Those parts of the kidney 
still unaltered undergo compensatory hypertrophy, and the 
remaining glomerulo-tubular systems thus modified become 
the seat of very pronounced activity. These glomeruli, with 
blood circulating in them at a very high pressure, filter out a 
great deal of fluid charged with excretory products. By this 
sort of balance which is maintained between the hypertrophic 
heart and blood at high pressure and the distended capillaries 
in the glomeruli, elimination becomes abundant, and even in- 
creased above the normal, when the heart is particularly 
strong. But if this compensation be broken by an infection 
bringing about a myocarditis or a glomerulo-tubulitis, then 
renal incompetency, more or less lasting, follows. Finally, 
the atrophic sclerotic process may eventually cause complete 
destruction of the glomeruli, and, elimination becoming 
lowered, the symptoms of uraemia set in. (La Semaine 
Medicale, No. 49, 1902). 4 

Abnormal Nitrogenous Metabolism. — Behrens puts the 
patient on a diet consisting of 1.5 liters of milk, 6 ^ggs, 250 
grammes of white bread and 45 grammes of butter daily for 
three or four days. The nitrogen in this diet amounts to 
about 13 grammes. The twenty-four hours' urine is collected 
and measured each day, the amount of urea determined by the 
usual methods and the quantity obtained multiplied by the 
fraction seven-twelfths, the result being the quantity of nitro- 
gen excreted. If the figure found differs materially from 13, 
the inference is that there is abnormal nitrogenous meta- 
bolism. 17 

Trauma as a Cause of Acute Nephritis. — Owing to injury, 
(1) the epithelial or connective tissue elements may be so 
affected as to degenerate, or (2) a reflex hypersemia may re- 
sult, or (3) microbic elements may find a favorable soil for de- 



RENAL INFARCT. SCARLATINAL NEPHRITIS. 673 

velopment. Cases are reported by Odin, Chevains, Roussel 
and Dock of nephritis following abdominal injuries. 

Renal Infarct. — After fully reporting a case of renal in- 
farct in a man of forty-five, Schmidt concludes that embolism 
in the renal artery causes acute vesical symptoms, retention 
of urine with incontinence. Polyuria follows, due to active 
hyperaemia with vasomotor paralysis. With this sudden pain 
and albuminuria are noted. Hsematuria but rarely occurs. 
All sorts of cells are found in the urinary sediment when renal 
infarct is present. When infarcts are bilateral, lying on the 
least-affected side causes an increase in the pain. Sudden 
vomiting may be the first symptom of an embolus of the renal 
artery. Though, a rise in temperature may occur, the condi- 
tion remains aseptic. When there is a suspicion of renal in- 
farct, sensory changes should be sought in the region supplied 
by the ilio-hypogastric nerve. 

Treatment of Scarlatinal Nephritis. — F. Huber recom- 
mends the following : 

If the case is seen early, and the urine is scanty and dark, 
plain or carbonated water with, a little bitartrate of potassium 
may be given frequently, and will often produce diuresis. 
Elimination through the skin and bowels should be encour- 
aged, but not simultaneously, for these organs are antagonistic 
in their functions. In the acute inflammatory state of the 
kidney, irritant diuretics are contra-indicated. Water, with 
or without cream of tartar or the other vegetable salts of 
potassium, should be given freely. 

Flushing the colon with hot normal salt solution, intro- 
duced high up in the rectum through a colon tube, will dilute 
the toxins and cause diuresis. Some favor the subcutaneous 
use of water by means of hypodermoclysis. 

Calomel, one-twentieth to one-tenth grn. every hour, is 
useful as a gastric sedative, a diuretic and a laxative. It may 
be continued for many days, stomatitis being a rare complica- 
tion. Ammonium carbonate in small and frequent doses is 

43 



674 CLINICAL MEMORANDA AND SUMMARY. 

serviceable in severe dyspnoea or threatening pulmonary 
oedema. Dry-cupping and strychnine may also be employed 
in such cases. Convulsions indicate hot packs, chloral per 
rectum, and salt water irrigations. In coma, the caffein- 
sodium benzoate may be given hypodermically as a stimulant 
and diuretic. Renal hemorrhage is treated by hot applica- 
tions over the loins, mustard plasters, and absolute rest. Hot- 
air baths and hot packs are useful in great oedema and 
dyspnoea. Alcohol is contra-indicated, but in severe cases 
dram doses of cold champagne and ice every ten to thirty 
minutes have tided the patient over the critical moment. 

Desperate cases frequently recover. As to convalescence, 
the patient must be kept in bed or at least indoors until all 
albumin disappears from the urine. The anaemia calls for 
iron, and the myocardial weakness for strychnine in suitable 
doses. Water, or carbonated water, should be given freely, 
and diet ought to be light and digestible. 1 

Baginsky {Jahrbuch fur Kinderheilkunde, vol. liv.) observed 
eighty-eight cases of scarlatinal nephritis in his hospital dur- 
ing the past five years. The earliest day of the scarlatina on 
which the nephritis developed was the sixth, and the latest 
was the thirtieth. The majority of the cases began with fever, 
and those with marked fever proved to be especially danger- 
ous. The quantity of urine was increased at first in some 
cases. In eighteen children a chronic albuminuria remained, 
and in five of these unmistakable signs of chronic nephritis 
developed. Cases treated in the hospital from the onset ran a 
decidedly more hopeful course than those admitted later. The 
cause of this is the treatment, consisting of four weeks' rest 
in bed and two weeks' absolute milk diet. Venesection is 
recommended for uraemia, and tannin for long-standing haem- 
aturia. 2 

Nephritis From Salicylates. — According to H. Luethje 
and others, salicylates are capable of producing true nephritis. 



THE KIDNEY OF PREGNANCY. 675 



THE KIDNEY OF PREGNANCY. 

K. A. Hertzfield, in Centralblatt f. Gynekologie (Leipsic), 
October 5, 1901, and translated in the Journal of the Ameri- 
can Medical Association, November 30, 1901, says: u In look- 
ing over trie reports of eighteen thousand dissections at the 
Vienna Institute of Pathology during the last ten years, 
eighty-one cases of eclampsia were found. In thirty-eight 
the record described indications of chronic nephritis ; in 
twenty -five, of parenchymatous degeneration of the kidneys, 
and in eighteen, compression of both ureters. Compression 
of the ureters was observed in the majority of the cases of 
eclampsia in primiparae. In thirty-two out of the eighty-one 
cases a haemorrhagic hepatitis was mentioned, with compres- 
sion of the ureters in four ; in twenty-one cases no macroscop- 
ical alterations were noted in the liver, but compression of the 
ureters had occured in ten. Chronic B right's disease, with 
more or less severe changes in the heart, was found in forty- 
six, 56 per cent, of the cases ; bilateral compression of the 
ureters in 22 3 per cent, and acute nephritis in 31. 1 per cent. 
The conclusion from these data seems evident that in the 
majority of cases of eclampsia there is an existing predisposi- 
tion to some lesion or affection of the urinary system. This 
assumption is further sustained by the fact that the cases in 
which the eclampsia appears in the early stages of pregnancy 
are considered the most severe. They are almost inevitable 
cases of pre-existing severe nephritic processes, an important 
point for the prognosis." * 

[In five cases of chronic nephritis which the author has 
seen and now has under observation, pregnancy and confine- 
ment were unaccompanied by eclampsia ; all the patients and 
all the children are alive. Four of the patients, however, be- 
came anaemic after confinement. One is apparently well at 
the present time, one year after confinement, but albumin is 
still present in small quantity in the urine.] 



676 CLINICAL MEMORANDA AND SUMMARY. 

The observations of Stroganoff on eclampsia are of interest. 
Of his one hundred and twenty-six cases, eight died. He 
concludes : 

From its pathological characteristics, eclampsia is a special 
form of disease which affects women in pregnancy, labor, in 
the puerperium, and rarely new-born children. It affects 
more frequently primiparse, twin pregnancies and women suf- 
fering from diseases of the kidneys. 

It is a disease of short duration, accompanied by some fever, 
and does not necessarily occur in the same women in succes- 
sive pregnancies, though it may be repeated in the same preg- 
nancy. 

In some years eclampsia occurs in a benign form, while in 
other years it is especially malignant. In some sections, also, 
it is a disease of great rarity. It is most frequently observed 
in lying-in hospitals. 

The disease may affect women with healthy kidneys, and 
in seventy per cent, of the cases the prodromal symptoms ap- 
pear before the attack (several hours). 

Eclampsia often occurs in groups of cases, as in lying-in 
hospitals, where it appears to follow other cases. The isola- 
tion of the eclampsia cases leads to a diminution of such cases 
in the clinic. 

The writer concludes from these premises that eclampsia is 
a special form of disease, with characteristic clinical, patho- 
logical and anatomical appearances ; that the theory of its 
foetal origin is not proven ; and that the theory of infection 
explains this disease in a more simple and a more logical 
manner, as the disease is more common in hospital than in 
private practice. 4 

Fehling mentions that eclampsia has occurred in his expe- 
rience in only five per cent, of his patients with "pregnancy 
albuminuria." The prognosis of "pregnancy kidney" is usu- 
ally favorable in the absence of eclampsia and premature de- 
tachment of the placenta. The latter is almost invariably 



THE KIDNEY OF PREGNANCY. 677 

fatal for the foetus. In case of chronic nephritis pregnancy 
should be prevented. If a pre-existing chronic nephritis be- 
comes much aggravated during a pregnancy the family phy- 
sician should consult with an obstetrician as to the advisabil- 
ity of inducing premature delivery. 2 

Judd, in the Brooklyn Medical Journal, advocates venesec- 
tion, Veratrum viride where the pulse is above sixty per 
minute, Morphine in half grain doses repeated if necessary, 
Choral by rectum in doses of 40 to 60 grains, hot wet pack, 
free catharsis by Croton oil or Blaterium if the patient is un- 
conscious, or Epsom salt if conscious, Chloroform to control 
convulsions, and saline effusion. 

Reddick has used Norwood's tincture hypodermic- 
ally in doses of from fifteen to thirty drops without bad 
results and in a number of cases there were no return of 
convulsions after the first dose. 

The Indications for the Induction of Labor. — (Hofmeier.) — 
In nephritis, as an indication for the induction of labor, we 
must differentiate between chronic nephritis and the nephritis 
of pregnancy. In chronic nephritis pregnancy is to be inter- 
rupted if, in spite of treatment, the secondary signs of the 
disease do not improve, but grow worse. In nephritis of 
pregnancy, special attention must be given to the danger of 
eclampsia and the operation is indicated if the symptoms pro- 
gressively increase in spite of dietetic treatment. 

The induction of premature labor for hyperemesis is oc- 
casionally necessary as a last resort. It is also necessary for 
albuminuria and nephritis if improvement does not follow a 
strict milk diet. In eclampsia of lesser degree Morphine and 
milk diet should be first tried. 

In amaurosis and retinitis, premature labor should be in- 
duced at once. Diabetes gravidarum has a bad prognosis ; 
one-fourth of the mothers die, and most of the children 
perish. 

Pregnancy should be interrupted in the earlier months, and 



678 CLINICAL MEMORANDA AND SUMMARY. 

in the second half if there is a high percentage of sugar 
otherwise, the operation may be delayed until the child 
is viable. 4 

Fever in Uraemia. — The cases are generally of two classes, 
first, those in which the symptoms are slow in approach and, 
second, those in which the onset is very sudden. The first 
class may resemble typhoid in the onset. A typical case of 
the second class, of rapid onset, is as follows : 

A case of acute nephritis in which the temperature is nor- 
mal until the patient shows symptoms of uraemia. The tem- 
perature quickly rises to 102 °, when convulsions appear, the 
temperature then jumps up toward 104 or thereabouts. 
After nearly a week of this condition there is a decline in the 
fever and the temperature remains normal until another at- 
tack of uraemia appears, which is ushered in by dimness of 
vision, headache and rise in temperature to about 101 . 
Stengel has reported a number of cases in which he has 
noted a rise in temperature before the first convulsion. He re- 
ports one case especially in which there was a period of five 
days of slow fever with a mild uraemic condition before con- 
vulsions appeared. 6 

Diet in Nephritis. — Koester has studied the effect of diet 
on the albumin and sediment in twenty -six cases of nephritis. 
His conclusions are as follows : 

Acute nephritis, or acute exacerbations of the chronic vari- 
ety, should be treated with strict milk diet as long as the ex- 
acerbation lasts. In chronic nephritis one may without risk 
allow a mixed diet, including both red and white meat, with 
exception of spices and alcohol. It is unimportant whether 
one give red or white meat. Ascites or oedema are no contra- 
indication to a mixed diet, if a patient desire it. At times it 
is of advantage to interrupt this diet, and to put the patient 
on milk alone for a while. 

Aasar agrees with Koester that a strict milk diet is insuffi- 
cient in chronic nephritis, and might be even injurious. He 



DIET IN NEPHRITIS. 679 

has seen patients who had been feeding on milk pick np after 
being allowed a mixed diet. Also, in a number of cases fol- 
lowing scarlatina and diphtheria, he has permitted a number 
of patients to have bread, fish, bread and butter, and a few a 
little meat, prohibiting coffee and alcoholic beverages. He 
has never observed any unfavorable results from these foods, 
nor has he seen uraemia follow. On the contrary, several pa- 
tients who had been drinking milk did become ursemic. 

Siven concludes from experiments on himself that one 
should attempt in nephritis to keep the patient on a diet poor 
in albumin, but rich in fat and carbo-hydrates. 4 

Favill holds that the general view that red meats are disad- 
vantageous for this class of patients is, to a certain extent, er- 
roneous, and that most of them can take red meats with as 
great impunity as white meats. 

W. H. Porter says: U A well regulated mixed diet, espe- 
cially if composed largely of the animal class, when it can be 
tolerated, yields the best results." Croftan opposes milk diet. 

The Treatment of Chronic Nephritis with Mineral Waters 
and Mineral Baths. — Von Noorden holds that water may be 
harmful. He announces, in the first place, that in cases of 
contracted kidney and the early stage of heart weakness the 
elimination of the products of metabolism is not influenced to 
any extent by a reduction of the amount of fluid taken daily. 
Albumin does not seem to be materially changed either by an 
increase or decrease in the amount of liquid ingested. More- 
over, in Bright's disease, when the heart is failing, a diminu- 
tion of the quantity of water proves beneficial. The reduc- 
tion of the quantity of liquid is advised in the early stages. 
Von Noorden has also noticed that after the ingestion of a 
large quantity of water in contracted kidney there is enlarge- 
ment and weakening of the heart. In the advanced stages, 
with a corresponding degree of arterio-sclerosis, with hyper- 
trophy of the heart, restriction of liquid is imperative. The 
average quantity of liquor advised is two pints. Prof. Bwald 
confirms Von Noorden. 



680 CLINICAL MEMORANDA AND SUMMARY. 

The bath treatment was based on the assumption that the 
action of the skin had a certain connection with the functions 
of the kidneys, and that by stimulating the former a disorder 
of the kidneys might be benefited. J. M. Groedel (Treatment 
of Chronic Nephritis, Practitioner, December, ipoi) has never 
seen any curative results from the drinking of waters. His 
experience is that the bath treatment, in cases of parenchy- 
matous (diffuse) nephritis, is contra-indicated. He divides 
cases of contracted kidneys into two groups. In the first 
group are those in whom the circulatory system is not greatly 
disturbed. The second group consists of those who show an 
advanced degree of insufficiency of the heart, which is more 
or less distinctly dilated. In the first group of cases the Nau- 
heim baths are suitable, but in the second group baths are 
contra-indicated. It has been said that carbonic acid saline 
baths always increase the blood pressure, but this is not the 
fact, and it has been proven that in cases of arterio-sclerosis we 
are able to regulate the baths in such a way as not to increase 
the blood pressure, but rather to reduce it. If this is the case, 
these baths should also be beneficial in contracted kidney. 
The baths of Nauheim have the effect of reducing the blood 
pressure for a longer period than the artificial baths. The 
more carbonic acid the bath contains, the more the tempera- 
ture may be lowered, but not below 90 ° F. The baths seem 
to dilate the peripheral vessels, a condition brought about by 
the irritation of the gas and the reduction of the blood press- 
ure ; they lighten the work of the heart and lead to a saving 
of that organ, which gives it a chance of recovering strength, 
and this is still further promoted by the direct stimulating 
and tonic effect of these baths. The increase in the diuresis 
is ascribed to the strengthening of the heart. 8 

Iyydston believes that decomposition of the gastro-intestinal 
juices, and gastromotor insufficiency may be produced by the 
ingestion of water in large quantities. 

(Edema and anasarca, while often relieved by the free in- 



MYELOPATHIC ALBUMOSURIA. 681 

gestion of water under favorable circumstances, are not in- 
frequently enhanced by it. 

Renal water habit may develop, by virtue of which the 
kidney becomes permanently sluggish, unless it receives its 
wonted stimulus of large quantities of water. 

Acute and chronic inflammatory affections of the kidney 
are sometimes aggravated by giving water in excess, simply 
by overworking the renal organs. 

Inflammatory affections of the lower portion of the genito- 
urinary tract are often deleteriously affected by excessive 
water-drinking, through the mechanical disturbances necessi- 
tated by the resultant frequent and copious micturition. 9 

Myelopathic Albumosuria. — This rare condition has been 
observed in about twenty cases. It occurs in the second half 
of life, from the age of thirty-six to seventy-one. The pro- 
portion, according to sex, has been three in men to one in 
women. The disease manifests itself in two ways, first, by 
an invasion of certain bones by a soft mass of new growth, 
and second, by the appearance in the urine of albumoses. 
The bones most often affected are the ribs, sternum and ver- 
tebral bodies. The new growth has a general resemblance 
to red marrow. The cold nitric acid test shows proteid in 
the urine, but the coagulum disappears on boiling. The cases 
terminate fatally, as in malignant disease. 

Chronic Nephritis and Senile Pneumonia. — The writer has 
seen several cases in which examination of the urine revealed 
albumin and tube-casts in such numbers as to suggest that 
the case was one of chronic nephritis, while the other clin- 
ical features were those of pneumonia. The cases of this 
character occur in the elderly. Some care is necessary in 
making a diagnosis under such circumstances. 

A striking feature of pneumonia, even in the early stages, 
before the diagnosis can be made with certainty is sometimes 
a marked increase in the amount of urea and total solids in 
the urine per twenty-four hours. When the patient is in bed, 



682 CLINICAL MEMORANDA AND SUMMARY. 

and on restricted diet, this increase is all the more significant. 
In one case the writer found more than six hundred grains of 
urea in the twenty-four hours' urine, one day before the diagno- 
sis could be made with certainty. During convalescence the 
urea and total solids diminished to the normal figures. The 
same increase, however, is not noticed with reference to the 
chlorides, which progressively diminish until at the height 
of the disease they may be entirely absent. 

In all cases of pneumonia the excretion of chlorides should 
be carefully watched. Obtain a Purdy percentage tube, 
graduated, and holding fifteen cubic centimeters, one-half a 
fluidounce. Fill it, every day, up to the mark 10 C.c. with 
filtered urine, add twenty-five drops of strong, pure, nitric 
acid, and fill up to the mark 15 C.c. with a solution of silver 
nitrate, containing one part, by weight, of the crystals, dis- 
solved in eight parts, by weight, of distilled water. Mix well 
and the dense white precipitate obtained may be allowed to 
settle of itself, which it will do in a few hours, or it may be 
settled in three minutes by use of the centrifuge. In either 
event the bulk of the precipitate can be measured. As long 
as the bulk of the precipitate shows diminution from day to 
day the patient is getting worse. When there is less than 
half of one cubic centimeter of it the disease is approaching 
the crisis, at which time there may be only one or two- 
tenths of a cubic centimeter, or, even no precipitate at all. 
When the precipitate begins to increase again, the patient is 
improving. Normally, there should be about. one cubic centi- 
meter of precipitate, or ten per cent, of the bulk of the whole 
fluid. If the urine contains albumin, remove it by boiling 
and filtration. 

In senile pneumonia, where the only symptoms may be 
weakness, a rise in temperature and increase in the number 
of respirations, the writer has, in several cases, as stated 
above, found a little albumin and numerous tube-casts in the 
urine. The casts have been always hyaline or granular. In 



OCULAR MANIFESTATIONS OF BRIGHT'S DISEASE. 683 

one case an unusually large number of hyaline casts was 
noticed and but few granular ; in another case numerous 
granular and but few hyaline. It is difficult to say whether 
these features in the urine were those of a previously existing 
chronic interstitial nephritis or not, as the previous history of 
the cases was not known to the writer. No oedema, how- 
ever, was present in either of them. 

Ocular Manifestations of Chronic Bright' s Disease.— The 
ocular lesions which may be seen associated with chronic 
nephritis are classified by Dr. G. M. de Schweinitz, as 
follows : 

i. Complete blindness, without ophthalmoscopic lesion. 
This occurs most often in acute nephritis, but also in acute 
exacerbations of chronic nephritis. 

2. Albuminuric retinitis and neuro-retinitis. Death usually 
within two years. 

3. Alterations in the caliber and relation of the retinal 
vessels, owing to sclerotic changes in their walls, with or 
without haemorrhages and exudates in the retina, seen in as- 
sociation with those forms of renal disease in which vascular 
changes are evident elsewhere in the body ; also isolated 
haemorrhages and exudates without marked vessel-wall 
changes. 

4. Alterations in the focal tract, particularly in the choroid 
and iris. The choroidal lesions are not evident to the 
ophthalmoscope, but can be seen only on microscopic ex- 
amination. 

5. Some varieties of cataract. A causal relation between 
nephritis and cataract has, however, never been established. 

6. Paresis and paralysis of the ocular muscles, particularly 
the superior oblique and the external rectus. They are rare, 
and may be terminal symptoms of albuminuria. 

7. Recurring subconjunctival haemorrhages. This mani- 
festation has not received the attention it deserves among the 
ocular signs of nephritis. In five cases three died within 
three years. 



684 CLINICAL MEMORANDA AND SUMMARY. 

The haemorrhages occur in persons past forty, and usually 
during sleep, the patients being surprised on waking to find 
an extravasation into the conjunctiva. An exactly analogous 
condition may appear in the delicate skin of the lower lid. — 
Proceedings of the Philadelphia Medical Society} 

Theocin as a Diuretic. — Theocin is the name given to the- 
ophyllin prepared synthetically. (Theophyllin is a com- 
pound, isomeric with theobromine and paraxanthin, and 
formerly made from tea extract at great cost.) The dose of 
Theocin is 0.3 to 0.5 grammes (4^ to 7^ grains) best ad- 
ministered dissolved in warm tea. Minkowski has used it in 
fourteen cases of dropsy from various causes, and its diuretic 
effect was manifested in all but two, in which vomiting al- 
ways occurred after its administration. Increase in the quan- 
tity of urine up to 3,000 to 5,000 c.c. was obtained. Its effect 
was not very lasting in some cases. 

Minkowski finds that it acts more powerfully and promptly 
than Theobromine, and in smaller doses. 

Turpentine in Flaxseed Poultices as a Diuretic. — In a case 
of chronic nephritis, in- which the urine was examined by the 
author, Muhlenberg, of Reading, Pa., made use of the follow- 
ing : Two teaspoonfuls of turpentine were stirred up in a flax- 
seed poultice and applied to the region of the kidneys. 
Clevenger, of Chicago, subsequently confirmed the efficacy of 
this treatment in the same case. 

Primary Chronic Interstitial Nephritis in Children. — Med- 
ical literature of the last five years has recorded several hun- 
dred cases of this disease in children between the ages of five 
and fourteen years. There have also been a few congenital 
cases reported. Baginsky has noticed a lack of development 
in children suffering from this disease ; children twelve or 
fourteen years of age may show a development equal only to 
that of half of these ages. The prognosis is very unfavorable. 
The disease lasts from two to four years in most cases and 
usually terminates in cerebral haemorrhage. Complete rest 



RENAL CALCULUS. LITH^EMIA. 685 

in bed with gentle massage once daily, milk diet in the main, 
and plenty of water to drink are valuable in the treatment, 
which medicinally is the same as in the case of adults and 
which, as in adnlts, is chiefly for controlling the more dis- 
tressing symptoms. M. B. Donglass advises digitalis tincture 
in cases of suppression of urine in chronic nephritis. 

Paroxysmal Hemoglobinuria in Children. — Herrman re- 
ports a case in a child which had hereditary syphilis. The 
urinary findings were similar to those in the case reported by 
the author due to scurvy from use of artificial foods. Herr- 
man's treatment was by Protiodide of Mercury and Peptonate 
of Iron. 

Pyonephrosis in Pregnancy. — Cumston, in the New York 
Medical Journal, describes a case of pregnancy complicated 
by pyonephrosis. Nephrotomy was first performed, but sep- 
tic symptoms set in twelve days after operation and nephrec- 
tomy had to be performed. Recovery took place and the pa- 
tient went to full term and was delivered without trouble. 

RENAL CALCULUS. LITELEMIA. 

Calculous anuria has been studied by various writers. In 
fifty-six cases which were not operated on, sixteen went on to 
recovery, while the other forty died, principally within a 
week. Of the fatal forty, ten were not examined after death ; 
of the others, twenty-three presented recent obliteration of one 
ureter, and seven showed one or more calculi in the pelvis 
capable of completely blocking the opening of the ureter. 
On the opposite side three kidneys were congenitally absent ; 
six showed atrophy or some other change due to calculi ; 
fourteen, various calculous lesions ; six, obliteration of the 
ureter, and one a healthy kidney. From these cases it is possi- 
ble to claim that anuria is not necessarily due to obliteration 
of the ureter, but that it may come from unfixed calculi in 
the pelvis of the kidney, without these causing absolute clos- 



686 CLINICAL MEMORANDA AND SUMMARY. 

ure of the ureter. Generally the opposite kidney is affected, 
although, in spite of the condition, it is, in a certain propor- 
tion of cases, capable of carrying on the function. Compar- 
ing the results of non-interference (a mortality of 71.5 per 
cent.) with those of surgical interference (eleven cures out of 
sixteen cases — 66.6 per cent.), the value of surgical treatment 
is at once apparent ; in the operation the position of the cal- 
culus must determine the details and the exact character of 
the procedure. Lumbar incision is generally the best, but the 
final decision of method must consider the question of ureter- 
otomy simply, and the creation of a urinary fistula in the 
lumbar region. 6 

Suppression of Urine from Renal Calculi. — A case is re- 
ported by Driggs in which total suppression of urine lasting 
fifteen days was due to impaction of both kidneys with calculi. 

Diagnosis of Renal Calculus. — Bennett does not seem to 
look with great confidence upon skiagraphs as an aid to diag- 
nosis, in this respect differing from a number of authorities. 
He claims that the negative result of the X-ray examination 
is "practically valueless." Leonard (four. A. M. A., Novem- 
ber jo, 1901) makes the most positive claim for the value of 
negative as well as positive results with the X-ray in cases of 
suspected renal and ureteral stone, and asserts that incision 
into the kidney for suspected calculus is only justified by the 
previous detection of the stone by the Rontgen method. 
Jonathan Hutchinson, Jr. {Brit. Med. Jour., October, iqoi) 
also expresses great confidence in the X-ray method, excepting 
in cases in which the patient is very fat and the stone very 
small. Bevan (Annals of Surgery, March, ipoi) says that 
the X-ray has revolutionized the diagnosis of renal stone and 
his experience regarding the value of this method corresponds 
to that of Leonard, who is probably its strongest advocate. 
He presents a skiagraph which shows a stone in the kidney 
which failed to be located during an exploratory incision of 
the kidney. He also tells us of cases in which multiple stones 



RENAL CALCULUS. LITH^MIA. 687 

have been demonstrated by the X-ray and yet the surgeon 
would probably have been contented with the removal of the 
largest of these. 8 

Passage of a Renal Papilla. — Smith has detailed an in- 
structive case as follows : " A plethoric man, of 45 years of 
age, who, after several weeks' illness with symptoms of 
hepatic disturbance, was taken seriously ill and went to bed, 
where he remained for a number of weeks with symptoms 
precisely those of acute Bright's disease. Fever ran high, 
the urine was scanty, high colored and smoky, containing 
casts of blood and granular matter. Examining the patient 
about a week after this second attack, a tender point was 
found over the left kidney upon deep abdominal palpation. 
This was supposed to be due to a pyelonephritis, probably 
from the presence of a calculus, and the other symptoms were 
referred to a similar cause. The symptoms gradually dimin- 
ished, the albumin left the urine and the patient was appar- 
ently convalescent from the attack, when an exacerbation oc- 
curred two weeks after the beginning of this second attack ; 
recrudescence of symptoms again occurred in two weeks, and 
in six weeks after this last. Finally, the patient handed his 
physician a small bit of tissue which he had passed with 
a considerable pain, by the urethra, two days after the final 
exacerbation of his symptoms. During this period of 
exacerbation the symptoms were those of renal colic, affect- 
ing the left side. After the passage of the tissue the patient 
rapidly recovered and resumed his business. Microscopical 
examination confirmed this to be a renal papilla." 6 

Ureteritis in the Female. — Garceau {Am. Jour, of the Med. 
Sci., Fed. y 18 9 j) classifies ureteritis as follows : (1) Simple 
ureteritis. (2) Ureteritis with obstruction. (3) Tubercular 
ureteritis. In simple ureteritis, using Kelly's cystoscope, he 
collects the urine from the ureters without admixture from 
vesical elements. He finds an excess of desquamated epithe- 
lium with or without pus in the urine from the affected side. 



688 CLINICAL MEMORANDA AND SUMMARY. 

Also diminution in the amount of urea in the urine from the 
affected side. 

A vaginally tender ureter is an important clinical sign. In 
treatment, a bland nutritious diet, avoiding asparagus and 
rhubarb, attention to the bowels and skin, and avoidance of 
fatigue are important. Patients should lead regular lives and 
have fresh air. Among drugs, bicarbonate of soda is valuable, 
and tonics. Alcohol and Morphine should be avoided. 
Trional in one or two ten-grain doses is best for sleeplessness. 
Relief is had from topical applications to the bladder (nitrate 
of silver, 5 or 10 per cent, and boric acid, 2 per cent.) or 
nitrate of silver, 1 per cent., in topical applications to the 
ureter by means of a new apparatus devised by Garceau. 

Vesico- vaginal fistula will somewhat relieve cases in which 
there is also well-marked cystitis. 

In ureteritis with obstruction there is either partial or 
complete obstruction. The chief cause of fibrous stricture is 
gonorrhoea. The symptoms are those of simple ureteritis and 
the chief distress is " a nagging desire to urinate." The 
diagnosis is made with ureteral bougies. Dilatation of the 
stricture relieves the symptoms. If gradual dilatation fails, 
the ureter is to be exposed through an extra-peritoneal in- 
cision, after preliminary introduction of a ureteral catheter, 
and the stricture cut. 

The diagnosis of ureteral calculus may be made from the 
history, the finding of blood in the urine from the affected 
side, lessened urea excretion on the affected side, feeling of 
the stone, if possible, by the finger in the vagina, use of the 
X-ray, and wax-tipped bougie. When the obstruction has 
existed for an appreciable length of time, the stone should be 
removed by extra-peritoneal operation. 

In complete obstruction of the ureter there may be agoniz 
ing pain on urinating or none at all. Acute attacks of pain 
in the kidney may be present, with fever, sweat, and gastric 
symptoms. Bi-manual examination of the bladder sometimes 
elicits pain. 



URETERITIS IN THE FEMALE. 689 

Pressure in the hypochondrium just below the ribs in the 
renal region generally evokes resistance of the abdominal 
muscles, a valuable sign of inflammatory renal disease. On 
the affected side pyuria is marked. The pus may have a 
fetid odor, albumin is present in large amount and the specific 
gravity of the urine is low. Difficulty is encountered in pass- 
ing the stricture with even a small-sized ureteral catheter. 
When the stricture is once passed, a gush of accumulated uriue 
and pus establishes the diagnosis. 

Four courses are open for consideration in the treatment of 
fibrous stricture with pyelonephritis and violent cystitis : The 
first is nephrectomy ; the second is gradual dilatation of the 
stricture with bougies, combined with repeated washings of 
the renal pelvis with antiseptic solutions carried up to the 
kidney by means of a long renal catheter ; the third is the 
performance of a cystotomy, with the idea of relieving the 
distressing symptoms on the part of the bladder and of allow- 
ing the kidney to go on to complete destruction, in the hope 
that it will atrophy and give rise to no further disturbance ; 
the fourth is making an artificial fistula above the strictured 
portion of the ureter. 

If it is tolerably certain that the kidney has ceased to be 
actively functionating, as determined by the examination of 
the separated urines, the methylene blue test, and by cryo- 
scopy, and it is fairly certain that it is not worth saving, the idea 
of nephrectomy may be entertained. Nephrectomy may some- 
times become imperative, as, for instance, when a general in- 
fection of the body threatens. Perinephritic abscess some- 
times supervenes in these cases of pyonephrosis ; and if the 
symptoms incident to such a complication are marked, as 
they are quite certain to be, the safest treatment is prelimi- 
nary incision and evacuation of the pus, and secondary 
nephrectomy later, when the patient has recuperated from the 
acute septic condition. 

The treatment of pyonephrosis associated with stricture by 
44 



690 CLINICAL MEMORANDA AND SUMMARY. 

means of dilatation of the stricture, combined with repeated 
washings of the renal pelvis with antiseptic solutions, has 
much to recommend it, and it is especially to be considered 
in those cases of pyonephrosis which have not yet been of 
sufficiently long duration to have destroyed a very large por- 
tion of the renal parenchyma. The method consists in pass- 
ing the renal catheter up to the renal pelvis through the 
stricture, which is at the same time dilated ; antiseptic solu- 
tions are then allowed to flow through the catheter, and local 
treatment is thus given every few days. 

It will sometimes happen that the patient will not enter- 
tain the thought of nephrectomy. In such a case it is es- 
sential to do something to relieve the distressing symptoms 
on the part of the bladder ; but if the kidney is the source 
of considerable disturbance from the accumulation of purulent 
urine within it, simple cystotomy will not give much relief, 
except in so far as it relieves the vesical symptoms. With a 
" silent " kidney, however, cystotomy will at once put the pa- 
tient in a condition of comparative comfort, and she enjoys 
life once more. It is possible at the end of many months 
that the kidney process may come to an end, and the final 
stage of inspissation and atrophy takes place. It is ..conceiv- 
able under such circumstances that the patient might get en- 
tirely rid of her infection and recover, in which case the 
fistula might be closed. 

A fistula above the stricture may sometimes have to be 
made if for any reason nephrectomy or other methods of treat- 
ment are impracticable. The indications are distressing focal 
symptoms on the part of a kidney. The fistula may. be made 
into the vagina, provided the stricture is low enough, or it 
may be made into the loin if the stricture is a high one. Sub- 
sequent nephrectomy should be entertained if this operation 
is practicable, depending on the decision of the patient and 
her general condition. 

Calculus in the ureter causing complete obstruction is 



"uric acid diathesis." 691 

recognized by history and symptoms of stone in the kidney 
preceding. The urine in complete obstruction will not flow 
on the affected side. Periodical discharges of pus point to 
intermittent complete closure 

The diagnosis is made by a careful survey of the previous 
history of the case. Previous attacks of hsematuria are of 
great diagnostic value, as are also attacks of colic. The X-ray 
should always be used to determine the seat of the stone ; it 
will not always be successful in locating it. If an exploratory 
incision is made into the kidney the diagnosis of ureteral ob- 
struction may be made by passing a sound into the ureter 
from above, but the same result is arrived at by ureteral 
catheterization through the vesical route. If the latter is done 
the nature of the obstruction cannot, however, be accurately 
determined. Vaginal touch will sometimes locate a stone, 
which may be felt as a hard mass under the examining finger. 

The treatment of complete obstruction is surgical. As to 
the kind of operation selected, this will depend on the condi- 
tion of the kidney and the length of time that impaction has 
existed. It is not proposed to discuss the various methods in 
detail. 

In tubercular ureteritis thickening of the ureter, found by 
vaginal examination, is quite characteristic. The ureter is 
felt as a solid cord running toward the pelvic brim. It 
is very tender, and pressure excites an urgent desire to urinate. 
Additional evidence is furnished by the history 7 of the case, 
the cystoscopic appearances and focal symptoms on the part 
of the kidney. Finding of the bacilli in the urine confirms 
the diagnosis. Total nephro-ureterectomy should be done in 
all cases in which the condition of the patient warrants it. 

" Uric Acid Diathesis. " — Dr. Charles Piatt, in discussing 
a paper on lithaemia, by Dr. Norton, states as his own belief 
that normally in mammals uric acid has a common origin 
with the nuclein bases in the katabolism of the nucleo-proteids 
that is not derived from the nuclein bases, neither from those 



692 CLINICAL MEMORANDA AND SUMMARY. 

of the body nor from those of the food ; that a certain small 
percentage in health and a larger percentage in disease — in 
disturbed hepatic metabolism — arises from glycocol, leucin, 
asparaginic acid, etc., which reach the liver via the portal 
tract. 

The term lithaemia is a poor name for a condition of tox- 
aemia, a poisoning of the sympathetic ganglia, a poisoning 
generally of intestinal origin. 

The Meaning of Uric Acid and Urates. — A notable view is 
the recent one of Woods-Hutchinson (Lancet, January j/, 

1903)' 

The uric acid produced in health comes exclusively from 

two sources, the larger moiety, or exogenous uric acid of 
Chittenden, from the nucleins and purin bases of the food, 
the smaller or endogenous moiety, from the destructive meta- 
bolism of the nucleins of the body-tissues. 

It is the endogenous moiety alone which is increased in gout 
and lithaemia. 

Gout and lithaemia are mere symptom names for a miscel- 
laneous group of chronic toxaemic processes of widely varied 
origin, characterized by the production of uric acid and 
urates. 

The uric acid of gout, like the phosphoric acid which in- 
variably accompanies it, is merely a result and measure of the 
destructive metabolism of the nucleins of the body-cells, 
chiefly probably of leucocytes, in response to the invasion of 
poisons or toxins, either organic or inorganic (lead, phos- 
phorus, alcohol, acetone). 

As most of the toxins setting up this destructive meta- 
bolism and consequent uric acid production are of intestinal 
origin or entry, diet in gout should be regulated solely with 
regard to the diminution of intestinal fermentation and 
putrefaction. 

As animal foods, from their much more appetizing and at- 
tractive flavors, are more apt to be indulged in in excess of 



"uric acid diathesis. 693 

the oxidative powers of the body, their limitation may be 
found to be more necessary than that of vegetable foods, but 
sugars and starches are also very often at fault. 

As uric acid and the alloxur group are not toxic, or at 
best feebly so, and are not the cause of gout, the prohibition 
of even foods rich in nucleins and purin bases, such as red 
meats, roe and sweetbreads, has no rational basis, and is clinic- 
ally of doubtful utility, except by diminishing the attractive- 
ness of the dietary. 

Sidonal in " Uric Acid Diathesis." — Freeman F. Ward, of 
New York, has used Sidonal extensively in the treatment of 
uric acid diathesis. Fifteen-grain doses in one-half glass of 
water one or two hours before meals were administered with 
benefit in cases where an excess of uric acid was found in 
the urine. In cases where very little or no uric acid was 
found the drug was of no avail, although it did no harm. 

"New Sidonal" (quinic acid anhydrid) has been given by 
Huber and Lichtenstein to gouty patients with benefit in 
daily doses of 2 ^ grammes. 

Weiss, of Basel, and Neumann, of Munich, use Quinic 
acid in combination with Lithium citrate in a preparation 
known as Urosine ; dose, six to ten tablets daily. Bach tablet 
contains 0.5 gm. Quinic acid, 0.15 gm. Lithium citrate and 0.3 
gm. sugar. 

Walker HalPs Purinometer. — Hall's method is based upon 
Camerer's method for the estimation of the total purin bodies 
in the urine. The urine is first freed from albumin. The 
phosphates are then precipitated by solution No. 1, which 
consists of 

Ivudwig's magnesium mixture, ioo c.c. 

Ammonia (20 per cent.), 100 c.c. 

Talc 10 grammes. 

After precipitation the phosphates are separated by turning 
a tap in the apparatus. The purin bodies are then precipi- 
tated by No. 2 solution, which consists of 



694 CLINICAL MEMORANDA AND SUMMARY. 

Silver nitrate, i gramme. 

Ammonia (strong), ioo c.c. 

Talc, 5 grammes. 

Distilled water, roo c.c. 

Ill an hour an approximate idea of the result can be ob- 
tained, and twenty-four hours later the precipitate can be read 
off on the graduated glass. Each cubic centimeter of the pre- 
cipitate represents o.ooio nitrogen. 

UROGENITAL TUBERCULOSIS. 

Frisch states that the discovery of bacilli in the urine is apt 
to be attended with difficulty both from the scarcity and the 
massive numbers to be encountered in different (or even in 
the same) specimens, at different examinations. One occur- 
rence of the bacilli, that in which they are arranged in S- 
shape groups, is especially valuable as a diagnostic sign of a 
urinary tuberculosis, but it is possible that even in such 
groups the tubercle bacilli may find their way into the urine 
from more distant tubercular foci. Nevertheless, these groups 
are more apt to come from masses of bacteria in close contact 
with the urine stream. Where the urine contains large quan- 
tities of mucus he suggests that it be treated with an alkali 
to dissolve the latter, thus permitting the precipitation of the 
bacilli. Where the sediment is largely made up of urates and 
other crystalline substances, he uses, after Wendriner, a solu- 
tion made of hot distilled water, in which is dissolved twelve 
per cent, of powdered borax, and afterward an equal amount 
of boracic acid added. This added to the urine dissolves the 
uric acid, urates, earthy phosphates and other organized sub- 
stances. The urine is permitted to stand until the sediment 
is deposited, then the supernatant fluid is poured off, the sedi- 
ment washed with water and collected upon a filter, and a 
portion of this pressed (but not rubbed) between two covers, 
dried and stained. 6 

Garceau concludes from a study of a large number of cases 



TUBERCULOUS CYSTITIS. 695 

that a patient who has been nephrectomized for tuberculosis 
should never consider that his future is safe, but should take 
the utmost care of himself. Out of 415 cases studied by Gar- 
ceau, 275 occurred between the ages of twenty and forty. 
Miliary tuberculosis is by far more common than caseous. 
It is quite possible for an obsolete tubercular process in some 
other part of the body to give rise to renal tuberculosis. In- 
fection through the urethra is not common. 

There is no question but that vesical tuberculosis as a 
primary disease is more common in males than in females, 
and it would appear also that the kidney is oftener affected 
primarily in males. 10 

TUBERCULOUS CYSTITIS. 

Tuberculous disease of the bladder is rarely primary, being 
generally secondary to a tuberculous condition of the prostate 
or kidney. Haematuria is the most frequent and probably 
the earliest symptom of the disease, so early in some instances 
that it may be called a prodromal symptom. It usually oc- 
curs at the end of urination, and varies in amount from a 
couple of drops to a teaspoonful. Pain is frequently present, 
commencing early and continuing through the course of the 
disease. At times it is so severe as to make one suspect cal- 
culus or malignant ulceration. Tenesmus is usually present. 
Frequency of urination is a fairly constant symptom, coming 
on early in some cases. As the disease progresses the symp- 
toms increase. Later pus is always found. The frequent 
voidance of clear urine without pain, with a few drops of 
bright red blood at the end of the urination, or less often pre- 
ceding it, is almost pathognomonic of beginning tuberculous 
cystitis. The pulse is quite suggestive, averaging from 90 to 
no, any sudden exertion increasing it to a considerable ex- 
tent. At present, Bissell (Phila. Med. Jour.) believes that the 
best chance of recovery is in eliminating the cause and build- 
ing up the resisting powers of the tissues of the body. 2 



696 CLINICAL MEMORANDA AND SUMMARY. 

Ureteral Catheter ism and Cystoscopy. — Guiteras, in an 
address delivered at the annual meeting of the American Uro- 
logical Association for 1902, says : " But few surgeons can be 
relied on to catheterize the ureters successfully." He thinks, 
however, that there is no doubt that the procedure is of great 
value in cases of renal diseases marked by morbid processes 
in the bladder, in cases of doubt as to the functional activity 
of the opposite kidney, and in furnishing a guide to the 
ureter, preventing its injury and securing drainage from be- 
low in renal operations. He takes exception to the advice of 
Kdebohls, who prefers bilateral lumbar incision to ureteral 
catheterism, on the ground that even if the kidney on the op- 
posite side is found to be present, it is by no means certain, 
by palpation of it, to determine whether it is normal or ne- 
phritic, or whether small stones or suppuration are present in 
it. Guiteras thinks also that the limitations of the Harris 
segregator are obvious. In fungous growths of the bladder 
and in other conditions of this viscus, which are accompanied 
by an easily bleeding surface ; in cases of deformed or con- 
tracted bladder, vesical calculus and hypertrophied prostate it 
cannot be expected to give accurate results ; while valuable 
in certain cases it cannot supplant ureteral catheterism. 

In connection with this subject the author wishes to em- 
phasize the statement already made in the body of this book, 
that tube-casts in number may sometimes be found in the urine 
after washing out the diseased bladder, the detection of which 
is impossible before this simple means has been adopted for 
finding them. 

According to Guiteras those who have special training and 
skill in cystoscopy do not now hesitate to operate by the aid of 
vision by means of the operating cystoscope perfected by 
Nitze, whereby cauterization, removal of growths, etc., in the 
bladder are made possible under the surgeon's eye without 
opening the organ. 

Vesical Spasm with Retention of Urine. — For the relief of 



VESICAL SPASM. CYSTALGIA. 697 

vesical spasm, with retention of urine, after the failure at 
catheterization and a sitz-bath, Mesnard gave i granule each 
of Bromhydrate of Cicutine and Hyoscyamine, every quarter of 
an hour. After an hour's use of these remedies, the patient, 
an old man, aged sixty-seven years, passed urine freely. Next 
day he complained of incontinence, and the Hyoscyamine was 
replaced by Sulphate of Strychnine, i granule every hour. 
He was eventually restored to health. On the other hand, 
Irwin overcame spasm with retention, in a boy, by urethral 
injection of Cocaine in 4 per cent, solution. In the case of a 
young man with a primary attack of gonorrhoea there oc- 
curred four days after the onset complete retention ; catheteri- 
zation was easily practiced, but the retention continued un- 
changed after the withdrawal of the urine. The man had no 
desire to urinate, and yet there was not the least obstruction 
to the passage of the catheter. Rochet in this case ad- 
ministered Ergot and electrical stimulation in the hypogastric 
region, with the result of quickly overcoming the symptom. 
A paralysis of the walls of the bladder from the intensity of 
the primary affection was probably the cause. 6 

Cystalgia. — This term is applied by certain French writers 
to a new variety of cystitis without peculiar anatomical 
features, but marked by excessive and intense pain, long 
duration, continued manifestation of symptoms without any 
long remission and entirely unrelieved by the ordinary thera- 
peutic measures. It occurs, especially in women with tuber- 
cular cystitis, following an overdistention of the bladder in 
lavage or careless use of vesical instruments. Frequence of 
micturition and pain are the two symptoms, which, from 
their importance and tenacity, distinguish this variety from 
other vesical inflammations. In a case of Marieux's the pa- 
tient urinated 120 times in the twenty-four hours ; the totality 
of urine is, however, but little increased. The pain is deep- 
seated, ill-defined, usually referred by the patient to the 
lower part of the bladder, rarely to the prostate gland, the 
base of the penis, the perineum, or the anus. 6 



698 CLINICAL MEMORANDA AND SUMMARY. 

Lydston says that neuralgia of the bladder is a very im- 
portant point for consideration, because of (i) the relative 
importance of pain, /<?r se, in diseases of the bladder; (2) the 
fact that very often no lesions are discoverable which explain 
the pain, or, at least, such lesions as are found appear too trivial 
to explain the severity of the pain experienced by the patient ; 
(3) the tendency to too radical treatment in the endeavor to 
relieve pain, by compelling a cure of lesions which are so 
slight that topical applications are likely to do harm rather 
than good. Cystalgia may occur with lesions of the genito- 
urinary apparatus, i: e., lesions affecting the urethra, bladder, 
kidneys, testis and spermatic cord ; with lesions of neighbor- 
ing organs, such as the prostate, rectum and anus. It may be in- 
cidental to ataxia or general paralysis, and be associated with 
gout, rheumatism, lead poisoning and malarial infection. There 
exists also an essential cystalgia. In the diagnosis the surgeon 
should be guided largely by the character and severity of any 
primary pathological condition that may be present, of an in- 
flammatory infectious character. He should also take into 
consideration the patient's general state. Care should be 
taken not to treat too radically lesions of the urinary way, 
the mildness of which is out of all proportion to the severity 
of the neuralgic manifestation. Narcotics, per os, hypoder- 
mically or per rectum ; hot applications to the hypogastrium, 
instillations of very weak cocaine or menthol solutions into 
the deep urethra or vesical neck are generally useful, but the 
constitutional treatment is by far the most important. 2 

Cystitis in Typhoid Fever. — Two distinct classes of cys- 
titis are recognized by Biss in typhoid fever — -those in which 
it is directly caused by retention, and perhaps by unclean 
catheterization, which cases may or may not be specific, and 
those, on the other hand, which are spontaneous in origin and 
certainly specific. Concerning frequency, the medium and 
severe cases seem to suffer most often ; the sexes are affected 
equally, and no differences are noted as to age. The average 



CYSTITIS. 699 

date of the appearance of bacilluria is the forty -third day ; 
of cystitis, the thirty-sixth. None of the theories which seek 
to account for a pathological basis are quite convincing, but 
it seems most likely that a multiplication of the bacilli takes 
place in the bladder. Sometimes not the typhoid, but. the 
colon and other bacteria, are the cause of the cystitis. Con- 
cerning treatment, Urotropin should be given as early as pos- 
sible without waiting to diagnose the bacillus. Of this, 20 
grains may safely be given every four hours, and the admin- 
istration should not be stopped too soon. Some forestall the 
appearance of a cystitis by giving the drug throughout the 
disease. 15 

Cystitis in La Grippe.— Breton {Gazette des Hopitaux) 
reports three cases in women of hemorrhagic cystitis in grip. 
Rest, milk diet, emollient drinks, hot vaginal douches, sup- 
positories of Opium and Belladonna ; internally, Turpentine 
and Benzoate of soda were the treatment. 

Treatment of Cystitis. — C. N. Cooper, of Cincinnati, uses 
Populus tremuloides (American aspen) in five drop doses of 
the first decimal every three hours for moderate cases, espe- 
cially in old men with enlarged prostate. He also recom- 
mends Pareira brava and Hedeoma (Squaw-mint). In chronic 
cases, Boracic acid in from ten to twenty grain doses for ster- 
ilizing the urine. 

Cooper says: " In acute cystitis hot body-baths are of value. 
Also, hot- water injections into the rectum as well as Opium 
suppositories. 

For the bladder cleansing, Borolyptol, Glyco-thymoline, 
Boracic acid (three per cent.), Potassium permanganate (two 
per cent.) are in daily use ; recently I have been more than 
pleased with the Borolyptol. 

Protargol, the Silver nitrate solution, is highly recom- 
mended ; personally, I have seen no good results, and doubt 
its medicinal value. 

Electrozone, or, so-called electrolocyzed sea-water, I have 



700 CLINICAL MEMORANDA AND SUMMARY. 

seen the best results from ; but with the caution of making 
sure it is a stable product. My experience is, it varies in 
strength ; recently having used one package with good effect, 
the second bottle setting free chlorine in excess, so as to re- 
quire prompt and liberal use of Albumen to antidote its 
ravages. 

Any wash, as a cleanser, should be introduced only after 
the bladder is emptied of urine, and then in measured quan- 
ties, varying as to the size of the bladder ; this application 
allowed to remain a few moments and again repeated, until 
the last withdrawn fluid is as clear as on introduction. In 
paretic cases, care must be taken to get back all the fluids 
used, in order to know in what condition, as to contents, the 
bladder is left. 

For healing or soothing purposes after cleansing, use a 
wash of one ounce of Fluid hydrastis, one ounce of Borolyp- 
tol, one ounce of Glycerine to a pint of warm water, adding 
Hamamelis one ounce, or Turpentine ten drops, as is best in- 
dicated, if there is tendency to bleeding. Many times from 
the excessive decomposition and accumulation of pus, blood, 
etc., we may fail to have its discharge by the catheter ; when 
fifteen to twenty grains of Pepsin dissolved in water, and 
thrown into the bladder, and allowed to remain one hour or 
less, will relieve the trouble. 

In prostatic complications a four per cent. Cocaine and 
L,anoline application to the gland, per rectum, will afford re- 
lief in many cases. Whatever solutions are used, the temper- 
ature should be about one hundred degrees when reaching 
the bladder, and not more than two ounces at one injection 
for the first sitting, or until the bladder grows more accus- 
tomed to larger quantities. 

The patient's position should be standing, if possible, that 
the drainage may be complete ; otherwise he should remain 
quiet, in bed, with the hips slightly elevated, that the bladder 
neck may be the least irritated." 15 



CYSTITIS. 701 

The author's attention has been called by Dr. C. S. Bl- 
dridge, of Chicago, to the efficacy of a preparation known as 
Methyloids in the treatment of cystitis. In a severe chronic 
case in a woman which had long resisted treatment by a 
number of agents, substantial and continued improvement 
followed the use of Methyloids, at first given two or three per 
twenty-four hours and subsequently one a day. Methyloids 
contain Methylene blue, Copaiba, Sandalwood oil, Haarlem oil 
and Cinnamon oil. B. G. Davis recommends Uriseptin. 

Adrenalin in Cystitis, Urethritis and Vaginitis. — In in- 
flammations of the bladder the organ is first washed out in the 
usual manner, and a mixture of solution Adrenalin chloride, 
four fluidrachms, and normal saline solution, thirty-six flui- 
drachms, is introduced and allowed to remain for five minutes. 
In inflammations of the deep urethra a few drops of the 
1:1000 solution may be introduced through a catheter. The 
passage of the sound or catheter in urethral stricture is facili- 
tated by allowing a few drops of the inoco solution of 
Adrenalin chloride to trickle through the instrument and 
come in contact with the obstruction. Inflammations of the 
vagina are most economically treated by mopping the vaginal 
walls with the cotton swab moistened with the 1:1000 solu- 
tion. 

Adrenalin in Hematuria. — In a case of slow oozing of 
blood from the bladder-walls Chassaignac used Adrenalin as 
follows : "I prepared a solution of Adrenalin chloride of 
1:20,000 by diluting the 1:1000 solution with normal salt 
solution. After rinsing out the bladder with Boric solution 
the organ was moderately filled with the Adrenalin solution, 
which was retained for five minutes and then permitted to es- 
cape. The effect was all that could be expected. The patient 
voided clear urine from this time until after midnight, when 
a pink tinge appeared and slowly deepened. In the morning 
the operation was repeated with a 1:24,000 solution. Again 
the urine became clear, and remained so all day and night. I 



702 CLINICAL MEMORANDA AND SUMMARY. 

made one more irrigation with a 1:30,000 solution. The pa- 
tient was warned of the risk of allowing his bladder to become 
distended, and was permitted to go home." l6 

J. S. Steiner, M. D., Bluffton, Ohio, writes that he with an- 
other physician tried for hours to pass a catheter into the 
bladder of a patient suffering with distention due to an en- 
larged prostate. Finally a hard-rubber catheter with a small 
fenestrum was chosen, and a syringe attached to the end of it. 
The catheter was introduced into the urethra, and by means 
of the syringe the solution of Adrenalin chloride was forced 
down against the resistant tissue. Owing to the powerful as- 
tringent effect of the Adrenalin, the caliber of the urethra was 
enlarged, and the catheter was passed into the bladder in less 
than five minutes. 

In operating on tumors of the bladder, and in performing 
supra-pubic cystotomy, Professor A. Von Frisch, of Vienna 
(Wiener Klinische Wochenschrift, No. 31), after opening the 
bladder, makes several applications of Adrenalin solution, 
1:1000, to the tumor and its immediate neighborhood, using 
a cotton pledget for the purpose. He states that this suffices 
perfectly to render possible the extirpation of the tumor in 
the blanched tissue, almost without any loss of blood whatever. 

At a recent meeting of the Southern Branch of the Biitish 
Medical Association {British Medical Journal, May 31, 1902), 
Mr. Rundle reported the case of a man suffering from severe 
hematuria, probably prostatic in origin. Various astringents 
had been tried without relief. After three injections of Adre- 
nalin chloride solution the urine became clear and continued 
so. Mr. Rundle considers Adrenalin worthy of further trial 
in similar cases. Dr. C. Knott had written concerning this 
treatment, and instanced a case recently under his care which 
was benefited thereby. 

Professor A. Von Frisch, of Vienna (Wiener Klinische 
Wochenschrift, No. 31), observes that in cystoscopic examina- 
tions in cases of vesical hsematuria the preliminary irrigations 



HELMITOL THE ANTISEPTIC. 703 

always cause a renewal of the haematuria, which interferes 
with examination. In such cases he fills the bladder with a 
solution of Adrenalin chloride i: 10,000, leaving the liquid in 
the viscus three to four minutes, after which the preliminary 
irrigations are begun. Thus he avoids all haemorrhage, or it 
is so slight that the clearing up of the contents of the bladder 
is readily effected, and the cystoscopic examination can be 
completed with perfect success. 

Helmitol as a Urinary Antiseptic. — Helmitol is a combin- 
ation of anhydromethylene citric acid with hexamethylene 
tetramin. After ingestion it is decomposed into methylene 
citric acid, or a salt of it, and hexamethylene tetramin. A 
certain portion of the methylene citric acid is excreted as free 
formaldehyde. 

The dose of Helmitol is from ten to twenty grains in water. 
It is said not to irrritate the kidneys. Rosenthal has used it 
in acute gonorrhceal cystitis, and in a case of chronic cystitis 
in an old man with benefit. 

Urinary Incontinence in Women. — A modified form of 
Brandt's treatment has cured urinary incontinence in women. 
The most essential part of this treatment is the direct treat- 
ment of the neck of the bladder by the finger in the rectum 
or the vagina. The following are the complete steps in this 
method of Brandt : 

1. Tapotement of the lumbar and sacral regions. The pa- 
tient stands with the feet together, bending slightly forward 
and supporting herself against a wall or some other firm ob- 
ject with her outstretched hands. A rapid, springy percussion 
is then made with the closed fist down both sides of the spine, 
beginning at the lumbar region and passing downward over 
the buttocks, after which the open hand is stroked firmly 
downward in the same direction several times. 

2. The patient in dorsal position on a low couch as for 
vaginal examination, the operator in front of the patient, 
right foot on the ground, left knee on the couch, then bends 



704 CLINICAL MEMORANDA AND SUMMARY. 

over the patient, extends his arms and lays his arms, ulnar 
surfaces approximated and finger-tips toward the pubes, on 
the woman's abdomen, in the hypogastrium. Sinking the 
fingers deeply into the abdomen as if to grasp the bladder, a 
hand on either side of it, a side-to-side motion is made with 
each hand several times. 

3. The index finger of the left hand is introduced into the 
vagina in such a manner as to partly encircle the neck of the 
bladder, and the right hand grasps the left wrist so as to reg- 
ulate more evenly the pressure. This done, the finger in the 
vagina is made to vibrate against the neck of the bladder, 
compressing it against the pubes with moderate force ; the 
same is then done for the other side of the neck of the blad- 
der. In children the finger is to be introduced into the rec- 
tum rather than into the vagina. 

4. Exercise of the adductors of the thighs. The patient in 
same position places her knees and heels together and raises 
her pelvis off the table, supporting herself on heels and shoul- 
ders. The operator now draws the knees apart, the patient 
resisting, three or fonr times, then, the patient pressing 
against his hands, the operator forces the knees together sev- 
eral times. 6 

Prostatic Hypertrophy. — Summing up the points favorable 
to the three operative procedures especially considered in this 
discussion, Bransford Lewis says: 

Favorable for the supra-pubic route : 

1. General enlargement of the prostate, with extreme 
intra- vesical projection of the median or lateral lobes, dimin- 
ishing their accessibility from the perineum. 

2. Marked pedunculation of the intra-vesical tumors, with 
absence of obstruction from other sources. 

Favorable for the perineal route : 

1. General hypertrophy, involving the median and lateral 
lobes, without extreme intra-vesical projection. 

2. Large or very thick bar formation ; marked compression 
of the urethra between the enlarged lateral lobes. 



OPERATIONS FOR PROSTATIC HYPERTROPHY. 705 

3. Excessive development of the prostate in the direction of 
the rectum. 

4. In most cases, where the patient is in good general con- 
dition and there is not a special indication favoring one of the 
other procedures. 

Favorable for the Bottini : 

1. Cases of extreme debility, unable to stand one of the 
severer operations. 

2. Cases of bar or medium sessile obstruction of not too 
great dimensions. 

3. Incomplete collar formation. 

4. Horwitz says it should be employed as a prophylactic 
against further obstructive hypertrophy, at the beginning of 
catheter-life. 

Supra-pubic cystotomy for drainage only is a palliative 
measure that has certain well-defined and highly advanta- 
geous features — not with reference to curing a case of prostatic 
obstruction, but for the purpose of improving conditions so 
that curative measures may be undertaken. It can be carried 
out under local (infiltration) anaesthesia, without adding to 
the seriousness of the conditions ; and the drainage that it 
affords may work wonders in the manner mentioned. 

As a substitute for this incision, being even milder still in 
its effects, Lewis commends a method as follows: Supra-pubic 
puncture with trocar and canula ; withdrawal of the trocar ; 
insertion of a soft-rubber catheter through the canula into the 
bladder ; withdrawal of the canula, leaving the catheter re- 
tained in the bladder, and held in place by safety-pins and 
proper bandages. He drained one case for ten days in this 
manner and without ill effect. 12 

N. P. Dandridge (A 7 ". Y. Med. Jour.) urges that we should 
not be carried away by the operative furor of the present 
time, but we should remember that the older methods still 
possess a large field of usefulness. There are, indeed, many 
cases in which surgery alone will relieve the obstructed uri- 

45 



706 CLINICAL MEMORANDA AND SUMMARY. 

nary flow and cure the cystitis. In a certain number of cases 
complete relief will follow simple perineal incision with drain- 
age for some weeks. It is in the large remainder that peri- 
neal prostatectomy promises a large field of usefulness. 

P. J. Freyer has totally extirpated the prostate in twenty- 
one cases by a new supra-pubic method. Death took place in 
two cases, one from acute mania on the twenty-fourth day, 
and the other from syncope on the ninth day. R. Harrison 
has had good results in five out of seven cases. 

Parker Syms believes' in the perineal operation, and has re- 
moved twenty-one without accidents or death. He has de- 
vised a special instrument to render easy traction on the pros- 
tate during its removal. 

URETHRITIS. 

Treatment by Argyrol. — Argyrol is a silver vitellin pro- 
duced from a proteid derived by chemical manipulation of 
wheat, and subsequently combined with silver. The high 
percentage of silver in the compound, its extreme solubility, 
and its intense penetrating action on the tissues constitute its 
chief scientific points of interest. Argyrol contains thirty 
(30) per cent, of silver, which is more than three times the 
amount in Protargol, the best known of the newer silver 
salts. The solubility of Argyrol is quite remarkable, one 
ounce of it being completely soluble in a dessertspoonful of 
water, consequently the salt may be employed in solution in 
any desired strength. 

H. M. Christian claims the following for Argyrol : 

(1) That it is absolutely free from any irritating properties, 
solutions as high as five per cent, causing no discomfort. 

(2) That the gonococci on and beneath the urethral mucous 
membrane are rapidly destroyed. 

(3) The amount of urethral discharge is, in a majority of 
cases, at once lessened in a marked degree. 



ARGYROL. BACTERIURIA. 707 

(4) The actual duration of the disease is shorter than is ob- 
tained by the use of any other silver salt. Thirty-eight out 
of forty-eight cases were cured in from two to four weeks. 

Nargol (nucleid of silver) is also used in the treatment by 
Baldwin, of Chicago. 

Bacteriuria. — I. Rosqvist calls attention to the irregularity 
and changeability of the clinical symptoms from the presence 
of bacteria in the urine, and especially to the severity of the 
general condition. He recommends irrigations of the bladder 
with from one-half to four per cent, solutions of silver nitrate. 
Frank H. Pritchard finds the Salol and Copaiba comp. for- 
mula of the New York Polyclinic, in capsuloids, efficacious. 4 

In one of the author's cases the patient claimed that the 
bacteriuria ceased after the drinking water used was boiled 
before taken. 

Epidural Injections for Incontinence of Urine. — Cathelin 
has treated eleven cases of incontinence of urine with epidural 
injections of salt solution in doses of from five to fifteen c.c, 
until, in several cases, thirty-five to forty c.c. have been given. 
In other cases he employed a five per cent, solution of Cocaine 
hydrochlorate. None of the patients treated in this manner 
presented any accident beyond headache and nausea, except 
that in one instance the child vomited. The children were 
not kept in bed, but were treated in the dispensary of the 
Hospital Necker. 13 

Diabetic Diet List. — The following strict diet is recom- 
mended by N. S. Davis {four. A. M. A.): Breakfast— Tea or 
coffee without sugar or cream, one egg and bacon, and two or 
three slices of nut bread with butter. Dinner — Bouillon or 
broth ; beef, mutton or chicken ; spinach, asparagus or wax 
beans ; salad of lettuce or tomatoes with cheese ; black coffee 
without sugar. Supper — Tea or coffee without sugar or 
cream ; meat, fish or mushrooms ; a salad of tomatoes, lettuce 
or chicory ; two or three slices of nut bread. At bedtime or 
in the evening an egg lemonade made with saccharin can be 



708 CLINICAL MEMORANDA AND SUMMARY. 



given. Use as much butter as possible on bread and oil on 
salads ; eat fat meats by preference. 6 

Potatoes in Diabetes. — Mosso uses a "potato cure" for the 
various forms of diabetes, substituting for bread i to 1.5 kilos 
(2.2 to 3.30 pounds avoirdupois) daily. 

Benzosol in Diabetes. — J. B. White has observed benefit 
from the use of Benzosol in diabetes. A tablet of the follow- 
ing constituents is recommended : 

Benzosol, i}4 gr. 

Lithium carb., i}4 gr. 

Sodium bicarb., . i]A gr. 

Potass, arsen. ; . , . J^ gr. 

Eucalyptus Tea in Diabetes. — Benefit has been reported 
from the use of a tea made from the leaves. The author used 
it in one case, but without the slightest apparent result. 

Aspirin in Diabetes Mellitus. — Van Noorden has called 
attention to the value of Aspirin in the treatment of diabetes 
mellitus. Williamson, of London, the well-known authority 
on diabetes mellitus, has used Aspirin in four cases of this 
disease of the less severe form, with good results in reducing 
the amount of sugar. The dose is at first ten grains twice or 
three times daily, increased to fifteen, four or five times daily, 
if no noises in the ears or toxic symptoms occur. The drug 
may be administered in the form of a powder to be taken in a 
tablespoonful of water, to which one or two drops of lemon 
juice are added, or it may be given in rice-flour capsules, 
Konseals so-called. 

Explicit instructions should always be given by the physi- 
cian to dip the sealed Konseal in water. It should then be 
placed well back on the tongue when it will readily collapse, 
and with a swallow of any fluid, preferably water, or even 
without any, the pressure of the tongue will cause the mass 
to assume the same form as would a similar portion of food 
well masticated and mixed with the saliva, when it is pleas- 
antly and easily swallowed. 



BIBLIOGRAPHY OF CLINICAL NOTES. 709 

[Physicians should see to it that their druggist is properly 
provided with the Konseal Apparatus for the filling and seal- 
ing of Konseals, which is furnished by the manufacturers, 
Messrs. J. M. Grosvenor & Company, Boston.] 

Supra-renal Extract in Diabetes. — Dr. B. F. Bailey, of 
Lincoln, Nebraska, has successfully used Supra-renal extract 
in the first decimal trituration in the treatmeut of threaten- 
ing gangrene of the toes in diabetes mellitus, 

Ergotole in Diabetes Insipidus. — Dr. M. J. Bliem reports 
"quick results" from use of Ergotole gtts x., four times daily 
for a week, in a case in which the patient was passing 96 
ounces of urine and 900 grains of urea. 4 

[Van Deusen, of Philadelphia, gave Scilla 2x dilution, 
twelve drops daily in six doses, successfully in a case of like 
nature.] 

Note on Edebohl's Operation. — Dr. G. F. Suker, of 
Chicago, has followed up the results of decapsulation of the 
kidneys with reference to retinitis. He finds that in seven- 
teen cases of double contracted kidney and retinitis death 
took place within two years after the operation in all the 
cases. He reasons that when cardio-vascular changes are 
present the operation is only of temporary benefit. 



BIBLIOGRAPHY OF CLINICAL NOTES. 

^Pediatrics. 

2 New Albany Medical Journal . 
3 American Pracliliofier and News. 
i Hahneman?iian Monthly. 
^British Medical Journal. 
6 New York Medical Times. 
7 Therapeutic Gazette. 
8 Ph iladelph ia Medica I Jou mal. 
9 The Medical News. 
10 The Boston Medical and Surgical Journal. 



710 CLINICAL MEMORANDA AND SUMMARY. 

n The Montreal Medical Journal. 

15 'Journal of Cutaneous and Genito- Urinary Surgery. 

1 *Ho m ceo pa th ic Jo u mat of Pedia tries . 

^University of Pennsylvania Medical Bulletin. 

n Medical Era. 

™New York Medical Journal. 

11 American Medicine. 



INDEX. 



Abnormal Metabolism, 672. 
Abscess of Bladder, 635. 
Abscess of the Kidney, 266. 
Absence of Kidneys, 70. 
Aconite, 97, no, 139, 148, 157, 238, 

244, 274, 443, 444. 
Actinomycosis, 264. 
Active Hypergemia of the Kidneys, 

93. 621. 
Acute Alcoholic Nephritis, 133. 

Dilatation of the Heart, 148. 
Diffuse Nephritis, 116. 
Diphtheritic Nephritis, 129. 
Glomerulo-Nephritis, 116. 
Interstitial Nephritis, 134. 
Acute Nephritis, 114, 622. 
from cold, 133. 
in typhoid fever, 130. 
in pneumonia, 130. 
Acute Nephritis of Gastro Enteritis, 

132. 
Acute Nephritis of Pregnancy, 149, 

623. 
Acute Parenchymatous Nephritis, 

114. 
Acute Post-Scarlatinal Nephritis, 

125. 
Acute Prostatitis, 637. 
Acute Uraemia, 77. 
Adrenalin, 701. 
Albuminoid Kidney, 252. 
Albuminuria, 48. 

cyclical, 49. 
Albuminuria, mortality from, 611. 

fatal cases, 617. 
Amyloid Kidney, 627. 
Anatomy of the Kidneys, 17. 
Anaemia of the Kidneys, 91. 



Aneurism of the Kidney, 91. 
Anomalies of the Kidney, 53. 
Anomalies of Number of Kidne) s, 69. 
Anomalies of Size of Kidneys, 69. 
Anuria, Calculous, 685, 686. 
Anuria from Anaesthetics, 98 
Apis, 139, 158, 184, 433. 
Apocynum can., in, 140, j 58, 193, 
194, 609. 

ARGENTUM NlTRICUM, 372. 
Argyrol, 706. 

Arnica, 98, no, 274, 433, 444. 
Arsenicum, 66, 183, 344, 396, 433, 

577- 
Arsenicum iodatum, 258. 
Arterio-sclerotic Kidneys, 247. 
Arterial Tension, 196. 
Aspirin, 708. 
Atrophy of Bladder, 403. 
Atrophy of the Kidneys, 205. 
AURUM MURIATICUM, 97, 238, 258. 

Bacteriuria, 707. 
Baptisia, 317, 438. 
Barosma, 345. 
Basham's Mixture, 183. 
Beeeadonna, hi, 140, 157, 243, 274, 

377, 433. 444- 
Benign Tumors, Renal, 287. 
Benzoic acid, 345, 433, 438. 
Benzosol, 708. 
Berberis, 345, 372, 433- 
Bladder, Diseases of, 404. 
Blood-vessels of the Kidney, 34. 
Bowman's Capsule, 33. 
Bryonia, 388, 504, 577. 

Caecarea carb., 317, 372. 
Caecarea hydriodica, 317. 



712 



INDEX. 



Calculus, Renal, 347. 
Camphora, 98, 434. 
Carcinoma (see Cancer). 
Cancer of Kidney, 289. 
Cancer of Prostate, 639. 
Cannabis Indica, 243, 373, 434. 
Cannabis sativa, 434. 
Cantharides, 140, 184, 343, 373, 

434, 439- 
Capsicum, 434. 
Capsular Nephrotomy, 198. 
Capsule of the Kidney, 23. 
Catheter, Use of, 446. 
Catheter Fever, 447. 
Chamomilla, 377. 
China, 317, 377. 
Chimaphiea, 344, 434, 494. 
Chronic Cystitis, 421. 

Degeneration (renal), 262. 
Chronic HcCmorrhagic Nephritis, 

164, 171, 172. 
Chronic Indurative Nephritis, 206, 

624. 
Chronic Interstitial Nephritis, 
primary, 206, 625. 
secondary, 204. 
Chronic Non-indurative Nephritis, 

161, 624. 
Chronic Nephritis, 161. 

Nephritis and Baths, etc., 679. 
Nephritis and Pneumonia, 681. 
Prostatitis, 638. 
Uraemia, 79. 
Chyluria, 398. 

ClCUTA VIROSA, 147. 

ClMIClFUGA, 388. 

ClNA, 527. 

Climatology, 181. 

Clinical Features of Renal Diseases, 

47- 
Clinical Notes, 671. 
Cloudy Swelling (renal), 261. 
Coccus cacti, 435. 
Collection of Urine, 665. 
Columns of Bertini, 25. 



Complications of Urinary Diseases, 
6 5 r. 

CONIUM, 435, 501. 

Contracting Kidney, 206, 625. 

ContractingKidney in Children, 684. 

Convoluted Tubules, 27. 

convaeearia, iio. 

Copaiba, 435. 

Cortex of the Kidney, 24. 

Crataegus, iii. 

Creosotum, 577. 

Crotaeus, 402. 

Cryoscopy, 77, 667. 

CUBEBA, 435. 

Cuprum Arsenicum, 140, 157, [59. 

Cylindruria, 6)2. 

Cystalgia, 697. 

Cystinuria, 397. 

Cystic Kidney, 627. 

Cystitis, 421. 

Treatmeut of, 431, 624. 
Cystitis, 

Adrenalin in, 701. 

in L,a Grippe, 699. 

Cooper's Treatment of, 699. 
Cystitis in Typhoid, 698 
Grippe, 699. 
Treatment of, 699. 
Cystocele, 404. 
Cystoplegia, 416. 
Cystospasmus, 417, 419. 
Cystoscopy, 696. 
Cysts of the Kidney, 280. 

Decapsulation of Kidneys, 709. 
Degenerations of the Kidney, 261. 
Delayed Renal Excretion, 73. . 
Development of the Kidney, 17. 
Diabetic Dietary, 707. 
Diabetes Insipidus, 60 r, 640. 
Diabetes Mellitus, 53T. 

blood, 552. 

clinical classification, 552. 
features, 542. 



INDEX. 



713 



Diabetes: coma, 586. 

complications, 554. 

course, 558. 

diagnosis, 541. 

diet, 564. 

etiology, 531. 

occurrence, 535. 

onset, 539. 

pathology, 536. 

post-mortem changes, 538. 

prognosis, 554. 

termination, 558. 

treatment, 558. 

of prodromal stage, 575. 
Diabetes Mellitus (Clinical Notes). 

aspirin in, 708. 

potatoes in, 708. 

benzosol in, 708. 

eucalyptus in, 708. 

ergotole in, 709. 

supra- renal extract in, 709. 
Diabetes Mellitus, summary of, 639. 
Diet in Nephritis, 678. 
Digitalis, no, 245, 377. 
Dilatation of Bladder, 405. 
Dimensions of the Kidney, 22. 
Diseases of Renal Pelvis, 321. 
Diverticula of Bladder, 404. 
Dropsy in Acute Nephritis, 123, 147. 

Renal Hypersemia, 105. 
Dulcamara, 98. 
Dyspnoea, 195. 

Eclampsia, 151. 

Edebohl's Operation, 198, 709. 

Effect on Retinitis, 709. 
Elimination of Urinary Solids, 671. 
Embolus of the Kidney, 90. 
Enuresis, 523. 

Treatment, 529, 707. 
Epidural Injections, 707. 
Epithelium of the Tubules, 30. 
Equisetum, 435. 
Ergotole, 709. 
Erigeron, 435. 



Eucalyptus, 97, 435. 
Eucalyptus tea, 708. 
Exstrophy of Bladder, 404. 

Fatty Change (renal), 262. 
Ferrum, 141, 183, 608. 
Fever in Uraemia, 678. 
Fistula of Kidney, 264. 
Floating Kidney, 54. 
Form of the Kidney, 22. 

Gelsemium, 66, 157, 389, 434, 444. 
Glanders, 264. 
Glomerulus, 33. 

Glonoin, 97, 148, 158, 239, 243. 
Glycosuria, 530. 

Gross Pathology, Synopsis, Non- 
suppurative Renal Lesions, 664. 

Hamamelis, 299. 
Headache, 195. 
Hedeoma, 389, 699. 
IlELLEBORUS NIGER, 141. 
Helmitol, 703. 
Helonias, 157, 609. 
Hekla lava, 274. 
Hsematoporphyrinuria, 402. 
Hsematuria, 399, 401, 701. 
Hemoglobinuria, 401, 685. 
Hepar sulphur, 258, 274. 
High Arterial Tension, 244. 
Horseshoe Kidney, 68. 
Hydatids. Renal, 284. 
Hydragogin, 190. 
Hydrastis, 258. 
Hydronephrosis, 322, 631. 
Hydrothionuria, 402. 
Hyoscyamus, 158, 436, 444. 
Hyperaemia of Renal Pelvis, 321. 
Hypersemia of Bladder, 420. 
Hypernephroma, 299. 
Hypertrophy of Bladder, 405. 
Hypertrophy of Prostate, 638, 705. 
Operations for, 705. 

IGNATIA, 66. 



714 



INDEX. 



Indicauuria, 402. 

Induction of Labor, 677. 

Inflammations of the Kidney, 112. 

Iodine, 249. 

Irritable Bladder, 405, 409. 

Taborandi, 141. 

Kali chloricum, 185, 402. 
Kali hydriodicum, 239, 258. 
Kali sulphuricum, 394. 
Kidney of Pregnancy, 675. 

Labyrinth of Ludwig, 20. 

Lachesis, 67, 158. 

Lactic acid, 577. 

Lactosuria, 402. 

Laevulosuria, 403. 

Lardaceous Kidney, 252. 

Large Mottled Kidney, 164, 171, 172. 

Large White Kidney, 161, 624. 

Leukemia, 264. 

Leprosy, 263. 

Lithsemia, 380, 685. 

Lithia, 97, 159, 388. 

Lithuria, 380. 

Lipaciduria, 402. 

Lipuria, 402. 

Lobulated Kidney, 68. 

Location of the Kidney, 17. 

Lycopodium, 258, 373, 436. 

Lycopus, 438 

Lymphatics of the Kidney, 23. 

Malformations of the Bladder, 404. 
Malformations of Renal Pelvis, 321. 
Malignant Tumors, Renal, 289, 633. 
Malpighian Tufts, 33. 
Markings of the Cortex, 25. 
Medulla of the Kidney, 25. 
Melanuria, 402. 
Mercurius biniodaTus, 258. 
Mercurius cor., 98, 142, 158, 184, 

240, 436, 504. 
Mercurius dulcis, 141, 240,243,250. 
Mercurius sol., 258. 



Metastatic Abscess of Kidney, 266. 
Methylene-blue Test, 74, 643. 
Methyloids, 701. 
Millefolium, 299. 
Milk Diet, 178. 

Mineral Baths in Nephritis, 679. 
Mineral Waters in Nephritis, 679. 
Misplacements of the Kidney, 53. 
Motor Neuroses, 417. 
Movable Kidney, 54, 621. 
Multilocular Cystic Kidney, 280. 
Myelopathic Albumosuria, 681. 

Nephritis — 

Acute, 114, 136. 

alcoholic, 133. 
Acute diffuse, 116. 

diphtheritic, 129. 
Acute glomerulo-, 116. 

interstitial, 134. 

in cholera, 131. 

in gastro-enteritis, 132. 

in pneumonia, 129. 

in pregnancy, 149. 

in plague, 131. 

in typhoid fever, 130. 

in yellow fever, 131. 

from exposure, etc., 133. 

parenchymatous, 174. 

post-scarlatinal, 125. 

suppurative, 266. 
Chronic, 161. 

arterio-sclerotic, 247. 

diffuse, 161. 

hemorrhagic, 164, 171. 

indurative, 204. 

interstitial, 204, 206. 

suppurative, 267. 
j Nephrolithiasis, 347. 
' Nerves of the Kidney, 23. 
Neuralgia of Bladder, 405. 
Nitric acid, 185, 241, 258, 317, 434. 
Nitrogenous Metabolism, 672. 
Normal Salt Solution, 195. 
Nucleoalbuminuria, 403. 



INDEX. 



715 



NUX VOMICA, 185, 241, 377, 389,436. 

Ocular Manifestations of Bright's 

Disease, 683. 
Operations on Prostate, 705. 
Opium, 158, 373. 
Oxaluria, 390. 

Pain in Urinary Diseases, 640. 
Paralysis of the Bladder, 416, 418. 
Paranephric Abscess, 274, 627. 
Parasites of Renal Pelvis, 347. 
Pareira brava, 573, 436. 
Paroxysmal Haemoglobinuria, 685 
Passive Renal Hypersemia, 99, 622. 
Pathology, Table of Gross, 664. 
Patient in Renal Diseases, 51. 
Patulous Urachus, 404. 
Pericarditis, 168. 
Paranephric Abscess, 274. 
Petroleum, 436. 
Phloriizin Diabetes, 76. 
Phosphaturia, 394. 
Phosphoric acid, 185, 258, 397, 

436, 577- 
Phosphorus, iio, 373, 402, 436. 
Physical Examination of the Kid- 
neys, 40. 
Pigmentations, Renal, 394. 
Piper methysticum, 436. 
Plumbum, 241, 437. 
Polygonum, 437. 
Populus, 437, 699. 
Position of Surfaces of the Kidney, 

19. 
Potatoes in Diabetes, 708. 
Prognosis (Clinical Notes) — 

Examination of urine in, 658. 

in acute nephritis, 659. 

in chronic nephritis, 659, 660. 

in puerperal nephritis, 661. 

in kidney of pregnancy, 661. 

in pneumonia, 662. 

in diabetes mellitus, 6b2. 

in Addison's disease, 662. 

in typhoid fever, 662. 



Prevesical Inflammation, 635. 
Prostate, Hypertrophied, 482, 704, 

705. 
Prostatitis, 501, 505, 507. 
Prostatic Abscess, 504, 638. 

Cancer, 508. 
Prunus spinosa, 437. 
Puerperal Eclampsia, 151. 
Pulmonary Edema, 149. 
Puriuometer, 693. 
Purulent Nephritis, 266. 
Pulsatilla, 66, 504. 
Pyelitis, 333, 629. 
Pyelo-nephritis, 266. 
Pyonephrosis, 330, 632, 685. 
Pyramids of Ferrein, 25. 

Renal- 
abscess, 628. 

calculus, 347, 630, 685. 

degenerations, 262. 

hypersemia, 93, 99, 622. 

embolism, 621. 

infarct, 673. 

inflammations (see nephritis). 

growths, 280. 

papilla, 687. 

permeability, 671. 

syphilis, 263. 

tenesmus, 377. 

tuberculosis, 305, 632. 

tumors (see growths). 
Relations of the Kidneys, 20, 21. 
Retinitis Albuminuria, 220, 709. 
Rhus aromatica, 527, 609. 
Rhus tox., 142. 

Sabal serrulata, 438. 
Sarcoma of Kidney, 289. 
Salicylates and Nephritis, 674. 
SanTalum, 437. 
Sarsaparilla, 373, 437. 
Scarlatinal Nephritis, 125, 673. 
SciLLA, 608. 
Scurvy in Children, 401. 
Secale, 501, 609. 



716 



INDEX. 



Section of the Kidney, 24. 

Senega, 437. 

Sepia, 373, 437. 

Sequences of Urinary Diseases, 650. 

Sieicea, 274. 

Solitary Kidney, 69. 

Stellated Veins, 35. 

Stone- 
in bladder, 635. 
in kidney, 347. 
in prostate, 510. 
in urethra, 513. 

Stigmata maidis, 344, 438, 494. 

Straight Tubules, 30. 

Stramonium, 158. 

Stroma, Renal, 36. 

Strophanthus, 109, 185, 250. 

Strychnia, 66, 250, 608. 

SuiyPHUR, 66, 438. 

Support of the Kidney, 22. 

Suppression of Urine, 686. 

Suppurative Nephritis, 266, 629. 

Supra-Renal Extract, 709. 

Surgical Kidney, 266. 

Syphilis of the Kidney, 263. 

Syzygium jamboeanum, 580. 

Tapotemeut for Incontinence, 703. 
TerebinThina, 97, 142, 158, 186, 

344, 438. 
Theocin, 684. 
Theories of Secretion, 37. 
Theaspi, 299, 374. 
Thrombosis. Renal, 89. 
Thuja, 437, 50 r, 609. 
Tissues of the Kidney, 26. 
Topography of the Kidney, 17. 
Tuberculosis — 

of bladder, 454, 635, 695. 

of kidney, 305, 346, 694. 

of prostate, 507, 638. 
Tumors of bladder, 464, 636. 
renal pelvis, 347. 
prostate, 508. 
Tunica Adiposa, 23. 



Turpentine Poultices, 684. 
Trauma of Kidney, 264, 672. 
Treatment of acute nephritis, 136. 

of chronic " 173, 23L 

of dropsy, 187. 

Unsymmetrical Kidney, 69. 
UrEemia, 71, 197, 644, 646. 
Ursemic Aphasia, 83. 
Ursemic Convulsions, 144. 

Fever, 678. 
Ursemic Paralysis, 81. 
Ursemic Ulcers, 87. 
Uranium nitricum, 158, 577. 
Uraturia, 380. 
Urea — 

relation to mortality, 615, 619. 
Ureteral Catheterism, 696. 
Ureteritis, 377, 633, 687. 
Uricaciduria, 380. 
Uric Acid Diathesis, 380, 691. 

Woods-Hutchinson theory, 692. 

Sidonal in, 693. 

Purinometer, 693. 
Uriuiferous Tubules, 27. 
Urinary Incontinence, 523, 703. 
in women, 703. 
in children, 523, 707. 
Uriseptin, 701. 
Urobilinuria, 403. 
Urotropin, 396. 

UVA URSI, 344, 438. 

Veratrum album, 377. 
Veratrum viride, 98, in, 142, 148, 

159, 274, 444. 

Vesical Hemorrhoids, 421. 
Vesical Spasm, 696. 
Vessels of the Kidney, 22. 
Vomiting in Nephritis, 148. 

Washing Out the Bladder, 444. 
Weight of the Kidneys, 22. 
Waxy Kidney, 252. 



SEP 2619G3 



